- 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
- $407.38 / $467.74 / $1,258.93
| Professional | | $407.38 | $467.74 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $457.09 / $794.33
| Professional | | $407.38 | $457.09 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $724.44 / $954.99
| Professional | | $512.86 | $724.44 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,000.00
| Professional | | $398.11 | $588.84 | $1,000.00 |