- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $630.96 / $1,621.81
| Professional | | $416.87 | $630.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $602.56 / $1,000.00
| Professional | | $457.09 | $602.56 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $851.14 / $1,230.27
| Professional | | $181.97 | $851.14 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $870.96 / $1,412.54
| Professional | | $537.03 | $870.96 | $1,412.54 |