- 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
- $104.71 / $1,202.26 / $3,630.78
| Professional | | $104.71 | $1,202.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $245.47 / $1,659.59
| Professional | | $109.65 | $245.47 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $346.74 / $3,235.94
| Professional | | $95.50 | $346.74 | $3,235.94 |
- 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
- $147.91 / $1,096.48 / $2,630.27
| Professional | | $147.91 | $1,096.48 | $2,630.27 |