- 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
- $269.77 / $741.63 / $2,891.45
| Professional | | $269.77 | $741.63 | $2,891.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.83 / $853.59 / $3,429.43
| Professional | | $507.83 | $853.59 | $3,429.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.45 / $1,133.08 / $4,731.88
| Professional | | $308.45 | $1,133.08 | $4,731.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.82 / $3,109.36 / $4,300.51
| Professional | | $2,634.82 | $3,109.36 | $4,300.51 |