- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $2,511.89
| Professional | | $933.25 | $1,000.00 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,621.81
| Professional | | $794.33 | $1,047.13 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $1,318.26 / $2,089.30
| Professional | | $269.15 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,137.96
| Professional | | $870.96 | $1,230.27 | $2,137.96 |