- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $3,981.07
| Facility | | $2,089.30 | $3,090.30 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $1,288.25
| Professional | | $407.38 | $575.44 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $467.74 / $758.58
| Professional | | $416.87 | $467.74 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $676.08 / $954.99
| Professional | | $512.86 | $676.08 | $954.99 |
- 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
- $389.05 / $549.54 / $1,000.00
| Professional | | $389.05 | $549.54 | $1,000.00 |