- 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
- $346.74 / $478.63 / $1,258.93
| Professional | | $346.74 | $478.63 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $489.78 / $794.33
| Professional | | $363.08 | $489.78 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $602.56 / $954.99
| Professional | | $151.36 | $602.56 | $954.99 |
- 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
- $371.54 / $575.44 / $1,000.00
| Professional | | $371.54 | $575.44 | $1,000.00 |