- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.17 / $2,162.17 / $9,011.12
| Facility | | $2,162.17 | $2,162.17 | $9,011.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.77 / $1,624.75 / $2,770.83
| Professional | | $323.77 | $1,624.75 | $2,770.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.29 / $257.17 / $392.73
| Professional | | $193.29 | $257.17 | $392.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.97 / $1,249.81 / $1,874.72
| Facility | | $151.97 | $1,249.81 | $1,874.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.00 / $2,640.00 / $5,904.00
| Professional | | $2,640.00 | $2,640.00 | $5,904.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.51 / $286.23 / $584.36
| Professional | | $172.51 | $286.23 | $584.36 |