- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.15 / $2,567.88 / $11,085.40
| Facility | | $1,027.15 | $2,567.88 | $11,085.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,511.65 / $1,647.31
| Professional | | $1,027.15 | $1,511.65 | $1,647.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,894.40 / $4,271.97 / $8,880.64
| Facility | | $1,894.40 | $4,271.97 | $8,880.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.91 / $2,538.79 / $3,531.05
| Professional | | $2,034.91 | $2,538.79 | $3,531.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $12,381.00
| Facility | | $8,702.00 | $8,702.00 | $12,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $1,162.81 / $1,976.77
| Professional | | $813.96 | $1,162.81 | $1,976.77 |