- 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
- $426.58 / $512.86 / $1,445.44
| Professional | | $426.58 | $512.86 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $851.14
| Professional | | $436.52 | $512.86 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $1,000.00
| Professional | | $575.44 | $691.83 | $1,000.00 |
- 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
- $380.19 / $575.44 / $1,122.02
| Professional | | $380.19 | $575.44 | $1,122.02 |