- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,348.96 / $9,772.37
| Professional | | $489.78 | $1,348.96 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $2,691.53 / $8,912.51
| Professional | | $446.68 | $2,691.53 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,096.48 / $13,182.57
| Professional | | $602.56 | $1,096.48 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $5,248.07 / $12,589.25
| Professional | | $537.03 | $5,248.07 | $12,589.25 |