- 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
- $166.64 / $764.00 / $1,552.68
| Professional | | $166.64 | $764.00 | $1,552.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,531.38 / $2,812.64 / $4,274.97
| Facility | | $2,531.38 | $2,812.64 | $4,274.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.70 / $580.41 / $2,656.98
| Professional | | $304.70 | $580.41 | $2,656.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.57 / $536.51 / $2,770.45
| Professional | | $260.57 | $536.51 | $2,770.45 |
- 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
- $258.75 / $1,569.96 / $2,749.63
| Professional | | $258.75 | $1,569.96 | $2,749.63 |