- 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
- $575.44 / $645.65 / $1,778.28
| Professional | | $575.44 | $645.65 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $660.69 / $1,071.52
| Professional | | $575.44 | $660.69 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,348.96
| Professional | | $724.44 | $1,000.00 | $1,348.96 |
- 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
- $549.54 / $794.33 / $1,412.54
| Professional | | $549.54 | $794.33 | $1,412.54 |