- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $8,511.38
| Facility | | $4,073.80 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $3,090.30 / $8,511.38
| Professional | | $977.24 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,495.41 / $6,606.93
| Professional | | $2,344.23 | $5,495.41 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $4,073.80 / $6,918.31
| Facility | | $933.25 | $4,073.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $3,311.31
| Professional | | $891.25 | $1,122.02 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,570.88 / $5,495.41
| Professional | | $2,344.23 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,244.36 / $12,882.50
| Facility | | $3,467.37 | $7,244.36 | $12,882.50 |