- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.15 / $405.47 / $1,668.51
| Professional | | $222.15 | $405.47 | $1,668.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.04 / $1,014.58 / $1,668.98
| Professional | | $256.04 | $1,014.58 | $1,668.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.82 / $468.40 / $2,809.99
| Professional | | $179.82 | $468.40 | $2,809.99 |
- 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
- $1,241.71 / $1,947.78 / $3,030.47
| Professional | | $1,241.71 | $1,947.78 | $3,030.47 |