- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $707.95 / $1,513.56
| Professional | | $575.44 | $707.95 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $645.65 / $1,000.00
| Professional | | $478.63 | $645.65 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $724.44 / $1,258.93
| Professional | | $151.36 | $724.44 | $1,258.93 |
- 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
- $512.86 / $758.58 / $1,258.93
| Professional | | $512.86 | $758.58 | $1,258.93 |