- 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
- $331.13 / $524.81 / $1,288.25
| Professional | | $331.13 | $524.81 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $467.74 / $851.14
| Professional | | $323.59 | $467.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $630.96 / $1,071.52
| Professional | | $436.52 | $630.96 | $1,071.52 |
- 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
- $371.54 / $549.54 / $1,000.00
| Professional | | $371.54 | $549.54 | $1,000.00 |