- 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
- $117.89 / $273.81 / $1,070.13
| Professional | | $117.89 | $273.81 | $1,070.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.81 / $537.09 / $943.40
| Professional | | $172.81 | $537.09 | $943.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.02 / $340.00 / $1,604.48
| Professional | | $166.02 | $340.00 | $1,604.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.37 / $1,057.63 / $1,394.36
| Professional | | $633.37 | $1,057.63 | $1,394.36 |