- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,370.32 / $10,232.93
| Facility | | $3,981.07 | $5,370.32 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $630.96 / $2,137.96
| Professional | | $407.38 | $630.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $5,623.41
| Facility | | $3,981.07 | $5,248.07 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $2,187.76
| Professional | | $616.60 | $616.60 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $724.44 / $1,071.52
| Professional | | $426.58 | $724.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $1,000.00
| Professional | | $630.96 | $870.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $741.31 / $1,479.11
| Professional | | $489.78 | $741.31 | $1,479.11 |