- 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
- $338.19 / $809.87 / $8,501.48
| Professional | | $338.19 | $809.87 | $8,501.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.67 / $1,112.83 / $11,174.39
| Professional | | $657.67 | $1,112.83 | $11,174.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.16 / $1,429.76 / $13,208.15
| Professional | | $395.16 | $1,429.76 | $13,208.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,065.00 / $10,745.00 / $44,924.00
| Facility | | $6,065.00 | $10,745.00 | $44,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,556.04 / $8,797.52 / $14,257.34
| Professional | | $6,556.04 | $8,797.52 | $14,257.34 |