- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $954.99 / $2,238.72
| Professional | | $707.95 | $954.99 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,548.82
| Professional | | $741.31 | $870.96 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $1,698.24
| Professional | | $912.01 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $13,182.57
| Facility | | $3,235.94 | $7,244.36 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,819.70
| Professional | | $691.83 | $1,000.00 | $1,819.70 |