- 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 / $1,174.90 / $3,981.07
| Professional | | $363.08 | $1,174.90 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,548.82 / $3,019.95
| Professional | | $389.05 | $1,548.82 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $851.14 / $4,073.80
| Professional | | $512.86 | $851.14 | $4,073.80 |
- 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
- $416.87 / $1,258.93 / $3,548.13
| Professional | | $416.87 | $1,258.93 | $3,548.13 |