- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $6,918.31 / $8,128.31
| Facility | | $2,137.96 | $6,918.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,344.23 / $2,511.89
| Professional | | $1,380.38 | $2,344.23 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,570.40 / $5,248.07
| Professional | | $2,454.71 | $2,570.40 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,691.53 / $87,096.36
| Facility | | $1,023.29 | $2,691.53 | $87,096.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $6,456.54
| Professional | | $1,995.26 | $3,019.95 | $6,456.54 |