- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $575.44 / $1,513.56
| Professional | | $457.09 | $575.44 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $489.78 / $831.76
| Professional | | $363.08 | $489.78 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $616.60 / $1,000.00
| Professional | | $181.97 | $616.60 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $660.69 / $912.01
| Professional | | $426.58 | $660.69 | $912.01 |