- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,981.07 / $10,232.93
| Facility | | $2,089.30 | $3,981.07 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $575.44 / $1,513.56
| Professional | | $467.74 | $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
- $89.13 / $616.60 / $1,000.00
| Professional | | $89.13 | $616.60 | $1,000.00 |
- 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
- $426.58 / $660.69 / $912.01
| Professional | | $426.58 | $660.69 | $912.01 |