- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $933.25 / $2,187.76
| Professional | | $851.14 | $933.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,445.44
| Professional | | $645.65 | $758.58 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $1,778.28
| Professional | | $676.08 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,709.64
| Facility | | $2,570.40 | $4,677.35 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $870.96 / $1,348.96
| Professional | | $602.56 | $870.96 | $1,348.96 |