- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $4,937.68
| Facility | | $3,706.14 | $3,955.04 | $4,937.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.65 / $395.64 / $1,299.54
| Professional | | $239.65 | $395.64 | $1,299.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.51 / $720.86 / $1,544.82
| Professional | | $382.51 | $720.86 | $1,544.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.69 / $686.34 / $2,836.46
| Professional | | $233.69 | $686.34 | $2,836.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.47 / $1,428.27 / $1,965.71
| Professional | | $1,027.47 | $1,428.27 | $1,965.71 |