- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $489.78 / $1,000.00
| Professional | | $302.00 | $489.78 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $426.58 / $794.33
| Professional | | $295.12 | $426.58 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $575.44 / $1,023.29
| Professional | | $398.11 | $575.44 | $1,023.29 |
- 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
- $338.84 / $501.19 / $933.25
| Professional | | $338.84 | $501.19 | $933.25 |