- 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
- $232.35 / $404.10 / $2,354.15
| Professional | | $232.35 | $404.10 | $2,354.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.06 / $1,081.46 / $2,847.65
| Professional | | $277.06 | $1,081.46 | $2,847.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.78 / $515.97 / $4,813.81
| Professional | | $190.78 | $515.97 | $4,813.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.92 / $3,011.66 / $4,960.18
| Professional | | $1,713.92 | $3,011.66 | $4,960.18 |