- 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
- $109.37 / $276.64 / $1,002.14
| Professional | | $109.37 | $276.64 | $1,002.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.98 / $354.31 / $1,199.60
| Professional | | $208.98 | $354.31 | $1,199.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.87 / $390.55 / $1,580.70
| Professional | | $132.87 | $390.55 | $1,580.70 |
- 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
- $848.52 / $1,017.98 / $1,316.71
| Professional | | $848.52 | $1,017.98 | $1,316.71 |