- 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
- $912.01 / $1,148.15 / $2,951.21
| Professional | | $912.01 | $1,148.15 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $1,621.81
| Professional | | $741.31 | $977.24 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $1,258.93 / $1,995.26
| Professional | | $89.13 | $1,258.93 | $1,995.26 |
- 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
- $851.14 / $1,258.93 / $1,819.70
| Professional | | $851.14 | $1,258.93 | $1,819.70 |