- 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
- $398.11 / $478.63 / $1,348.96
| Professional | | $398.11 | $478.63 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $489.78 / $812.83
| Professional | | $436.52 | $489.78 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $676.08 / $1,000.00
| Professional | | $549.54 | $676.08 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $1,071.52
| Professional | | $389.05 | $562.34 | $1,071.52 |