- 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
- $309.03 / $562.34 / $1,318.26
| Professional | | $309.03 | $562.34 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $478.63 / $831.76
| Professional | | $302.00 | $478.63 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $602.56 / $1,023.29
| Professional | | $398.11 | $602.56 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $512.86 / $977.24
| Professional | | $316.23 | $512.86 | $977.24 |