- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $3,630.78 / $8,317.64
| Professional | | $776.25 | $3,630.78 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $3,801.89 / $7,943.28
| Professional | | $707.95 | $3,801.89 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $1,584.89 / $13,182.57
| Professional | | $251.19 | $1,584.89 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $19,952.62
| Facility | | $4,466.84 | $8,128.31 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,445.44 / $11,220.18
| Professional | | $812.83 | $1,445.44 | $11,220.18 |