- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,786.30 / $8,709.64
| Facility | | $2,398.83 | $4,786.30 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $660.69 / $1,548.82
| Professional | | $380.19 | $660.69 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $537.03 / $1,000.00
| Professional | | $380.19 | $537.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $724.44 / $1,288.25
| Professional | | $426.58 | $724.44 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $630.96 / $1,174.90
| Professional | | $363.08 | $630.96 | $1,174.90 |