- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,479.11 / $3,467.37
| Facility | | $1,023.29 | $1,479.11 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $1,778.28
| Professional | | $758.58 | $1,174.90 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $2,754.23
| Facility | | $1,122.02 | $1,412.54 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,584.89
| Professional | | $691.83 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $457.09 / $758.58
| Professional | | $363.08 | $457.09 | $758.58 |