- 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
- $323.59 / $389.05 / $1,000.00
| Professional | | $323.59 | $389.05 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $354.81 / $630.96
| Professional | | $309.03 | $354.81 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $602.56 / $758.58
| Professional | | $398.11 | $602.56 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,912.51
| Facility | | $2,570.40 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $489.78 / $794.33
| Professional | | $323.59 | $489.78 | $794.33 |