- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $467.74 / $1,288.25
| Professional | | $389.05 | $467.74 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $478.63 / $758.58
| Professional | | $363.08 | $478.63 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $741.31 / $1,000.00
| Professional | | $467.74 | $741.31 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $616.60 / $977.24
| Professional | | $426.58 | $616.60 | $977.24 |