- 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
- $206.78 / $558.85 / $1,855.84
| Professional | | $206.78 | $558.85 | $1,855.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.68 / $645.29 / $2,439.32
| Professional | | $382.68 | $645.29 | $2,439.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.02 / $675.23 / $3,129.09
| Professional | | $280.02 | $675.23 | $3,129.09 |
- 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
- $1,625.73 / $1,950.32 / $3,354.48
| Professional | | $1,625.73 | $1,950.32 | $3,354.48 |