- 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
- $162.76 / $405.15 / $1,978.13
| Professional | | $162.76 | $405.15 | $1,978.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.39 / $530.88 / $2,304.06
| Professional | | $313.39 | $530.88 | $2,304.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.98 / $715.27 / $3,288.85
| Professional | | $198.98 | $715.27 | $3,288.85 |
- 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
- $1,801.06 / $2,108.05 / $2,937.27
| Professional | | $1,801.06 | $2,108.05 | $2,937.27 |