- 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
- $645.65 / $933.25 / $2,344.23
| Professional | | $645.65 | $933.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,445.44
| Professional | | $630.96 | $851.14 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,071.52 / $1,737.80
| Professional | | $181.97 | $1,071.52 | $1,737.80 |
- 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
- $724.44 / $1,047.13 / $1,819.70
| Professional | | $724.44 | $1,047.13 | $1,819.70 |