- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $7,364.91
| Facility | | $3,706.14 | $3,955.04 | $7,364.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.33 / $740.46 / $3,037.59
| Professional | | $303.33 | $740.46 | $3,037.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.82 / $937.63 / $3,742.82
| Professional | | $554.82 | $937.63 | $3,742.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.68 / $1,307.22 / $4,860.04
| Professional | | $349.68 | $1,307.22 | $4,860.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.77 / $3,206.29 / $4,370.03
| Professional | | $2,763.77 | $3,206.29 | $4,370.03 |