- 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
- $457.09 / $1,288.25 / $12,022.64
| Professional | | $457.09 | $1,288.25 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $2,511.89 / $8,912.51
| Professional | | $416.87 | $2,511.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,023.29 / $13,182.57
| Professional | | $562.34 | $1,023.29 | $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
- $501.19 / $5,248.07 / $12,589.25
| Professional | | $501.19 | $5,248.07 | $12,589.25 |