- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.25 / $287.81 / $2,456.32
| Professional | | $120.25 | $287.81 | $2,456.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.88 / $438.75 / $3,228.60
| Professional | | $257.88 | $438.75 | $3,228.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.69 / $508.10 / $4,620.33
| Professional | | $158.69 | $508.10 | $4,620.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.67 / $2,862.15 / $4,567.81
| Professional | | $2,165.67 | $2,862.15 | $4,567.81 |