- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,278.83 / $3,233.34 / $7,778.23
| Facility | | $2,278.83 | $3,233.34 | $7,778.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.28 / $1,116.64 / $1,289.21
| Professional | | $1,025.28 | $1,116.64 | $1,289.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,853.48 / $2,950.63 / $6,124.59
| Facility | | $1,853.48 | $2,950.63 | $6,124.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.13 / $1,015.13 / $1,015.13
| Professional | | $1,015.13 | $1,015.13 | $1,015.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.40 / $983.40 / $1,306.04
| Facility | | $983.40 | $983.40 | $1,306.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,008.06 / $6,008.06 / $6,008.06
| Professional | | $6,008.06 | $6,008.06 | $6,008.06 |