- 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
- $776.25 / $977.24 / $2,511.89
| Professional | | $776.25 | $977.24 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,380.38
| Professional | | $630.96 | $831.76 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $1,071.52 / $1,698.24
| Professional | | $89.13 | $1,071.52 | $1,698.24 |
- 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
- $724.44 / $1,071.52 / $1,548.82
| Professional | | $724.44 | $1,071.52 | $1,548.82 |