- 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
- $190.02 / $357.33 / $2,326.55
| Professional | | $190.02 | $357.33 | $2,326.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.16 / $846.31 / $2,212.01
| Professional | | $202.16 | $846.31 | $2,212.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.05 / $413.69 / $3,928.30
| Professional | | $228.05 | $413.69 | $3,928.30 |
- 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
- $1,735.48 / $2,722.97 / $4,239.30
| Professional | | $1,735.48 | $2,722.97 | $4,239.30 |