- 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
- $537.03 / $851.14 / $2,344.23
| Professional | | $537.03 | $851.14 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $1,513.56
| Professional | | $831.76 | $933.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $1,737.80
| Professional | | $891.25 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $1,778.28
| Professional | | $676.08 | $870.96 | $1,778.28 |