- 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
- $851.14 / $1,071.52 / $2,754.23
| Professional | | $851.14 | $1,071.52 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,513.56
| Professional | | $691.83 | $912.01 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $1,148.15 / $1,862.09
| Professional | | $89.13 | $1,148.15 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $11,220.18
| Facility | | $2,818.38 | $5,128.61 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,174.90 / $1,737.80
| Professional | | $794.33 | $1,174.90 | $1,737.80 |