- 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
- $478.63 / $660.69 / $1,230.27
| Professional | | $478.63 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $562.34 / $831.76
| Professional | | $426.58 | $562.34 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $645.65 / $1,174.90
| Professional | | $398.11 | $645.65 | $1,174.90 |
- 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
- $389.05 / $645.65 / $1,000.00
| Professional | | $389.05 | $645.65 | $1,000.00 |