- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $10,964.78
| Facility | | $4,466.84 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $977.24 / $3,388.44
| Professional | | $831.76 | $977.24 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $1,621.81
| Professional | | $912.01 | $1,174.90 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,471.29 / $16,595.87
| Facility | | $6,606.93 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $3,890.45
| Professional | | $870.96 | $1,230.27 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,585.78 / $15,135.61
| Facility | | $3,630.78 | $7,585.78 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $2,344.23
| Professional | | $707.95 | $1,000.00 | $2,344.23 |