- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $446.68 / $831.76
| Professional | | $269.15 | $446.68 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $676.08
| Professional | | $281.84 | $407.38 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $512.86 / $1,000.00
| Professional | | $151.36 | $512.86 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $467.74 / $812.83
| Professional | | $275.42 | $467.74 | $812.83 |