- 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
- $537.03 / $616.60 / $1,698.24
| Professional | | $537.03 | $616.60 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $616.60 / $1,000.00
| Professional | | $537.03 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,258.93
| Professional | | $676.08 | $954.99 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $1,318.26
| Professional | | $537.03 | $758.58 | $1,318.26 |