- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.64 / $233.36 / $1,814.51
| Professional | | $32.64 | $233.36 | $1,814.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.56 / $95.70 / $3,212.72
| Professional | | $48.56 | $95.70 | $3,212.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.66 / $2,872.74 / $4,248.13
| Professional | | $1,643.66 | $2,872.74 | $4,248.13 |