- 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
- $363.08 / $851.14 / $2,238.72
| Professional | | $363.08 | $851.14 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $660.69 / $1,479.11
| Professional | | $295.12 | $660.69 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $912.01 / $2,344.23
| Professional | | $269.15 | $912.01 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $812.83 / $1,621.81
| Professional | | $346.74 | $812.83 | $1,621.81 |