- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $416.87 / $1,000.00
| Professional | | $295.12 | $416.87 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $354.81 / $724.44
| Professional | | $316.23 | $354.81 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $549.54 / $741.31
| Professional | | $380.19 | $549.54 | $741.31 |
- 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
- $302.00 / $478.63 / $776.25
| Professional | | $302.00 | $478.63 | $776.25 |