- 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
- $588.84 / $758.58 / $1,905.46
| Professional | | $588.84 | $758.58 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $707.95 / $1,148.15
| Professional | | $537.03 | $707.95 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,659.59
| Professional | | $758.58 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,023.29 / $1,659.59
| Professional | | $588.84 | $1,023.29 | $1,659.59 |