- 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
- $954.99 / $1,047.13 / $2,454.71
| Professional | | $954.99 | $1,047.13 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,621.81
| Professional | | $741.31 | $870.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $2,041.74
| Professional | | $776.25 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,513.56
| Professional | | $691.83 | $1,000.00 | $1,513.56 |