- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $5,128.61
| Facility | | $3,162.28 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $794.33 / $1,995.26
| Professional | | $575.44 | $794.33 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,981.07
| Facility | | $3,235.94 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $2,187.76
| Professional | | $741.31 | $741.31 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $812.83 / $1,348.96
| Professional | | $436.52 | $812.83 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $1,000.00
| Professional | | $616.60 | $812.83 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $831.76 / $2,454.71
| Professional | | $676.08 | $831.76 | $2,454.71 |