- 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
- $1,148.15 / $1,513.56 / $4,265.80
| Professional | | $1,148.15 | $1,513.56 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $2,290.87
| Professional | | $851.14 | $1,000.00 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,398.83
| Professional | | $891.25 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $1,949.84
| Professional | | $831.76 | $1,258.93 | $1,949.84 |