- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,630.78 / $3,981.07
| Facility | | $2,089.30 | $3,630.78 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $602.56 / $1,513.56
| Professional | | $501.19 | $602.56 | $1,513.56 |
- 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 / $851.14 / $1,174.90
| Professional | | $676.08 | $851.14 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $691.83 / $1,318.26
| Professional | | $457.09 | $691.83 | $1,318.26 |