- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $602.56 / $1,288.25
| Professional | | $346.74 | $602.56 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $562.34 / $1,023.29
| Professional | | $331.13 | $562.34 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $776.25 / $1,412.54
| Professional | | $457.09 | $776.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $676.08 / $1,318.26
| Professional | | $363.08 | $676.08 | $1,318.26 |