- 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
- $59.43 / $108.14 / $1,282.65
| Professional | | $59.43 | $108.14 | $1,282.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.86 / $243.43 / $1,191.20
| Professional | | $61.86 | $243.43 | $1,191.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.72 / $125.00 / $2,050.39
| Professional | | $66.72 | $125.00 | $2,050.39 |
- 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
- $1,017.00 / $1,421.26 / $1,801.73
| Professional | | $1,017.00 | $1,421.26 | $1,801.73 |