- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.91 / $291.87 / $3,217.75
| Professional | | $132.91 | $291.87 | $3,217.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.81 / $826.13 / $3,415.74
| Professional | | $200.81 | $826.13 | $3,415.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.73 / $397.24 / $6,104.76
| Professional | | $202.73 | $397.24 | $6,104.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,371.68 / $4,123.41 / $5,430.37
| Professional | | $3,371.68 | $4,123.41 | $5,430.37 |