- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,981.07 / $5,128.61
| Facility | | $2,511.89 | $3,981.07 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $851.14 / $3,388.44
| Professional | | $323.59 | $851.14 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $1,288.25 / $2,570.40
| Professional | | $223.87 | $1,288.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $549.54 / $3,981.07
| Professional | | $199.53 | $549.54 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,471.29
| Facility | | $2,818.38 | $5,128.61 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $549.54 / $3,630.78
| Professional | | $275.42 | $549.54 | $3,630.78 |