- 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
- $54.54 / $1,000.00 / $1,805.79
| Professional | | $54.54 | $1,000.00 | $1,805.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.95 / $159.56 / $3,197.59
| Professional | | $80.95 | $159.56 | $3,197.59 |
- 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
- $1,516.20 / $2,941.76 / $4,495.00
| Professional | | $1,516.20 | $2,941.76 | $4,495.00 |