- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.37 / $848.68 / $10,937.34
| Professional | | $490.37 | $848.68 | $10,937.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.87 / $2,505.86 / $9,024.98
| Professional | | $508.87 | $2,505.86 | $9,024.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.98 / $1,059.11 / $12,879.75
| Professional | | $741.98 | $1,059.11 | $12,879.75 |
- 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
- $5,773.53 / $9,535.44 / $14,851.48
| Professional | | $5,773.53 | $9,535.44 | $14,851.48 |