- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $5,370.32 / $7,943.28
| Facility | | $1,023.29 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $2,570.40
| Professional | | $645.65 | $1,000.00 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,659.59 / $6,606.93
| Facility | | $891.25 | $1,659.59 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,659.59 / $2,454.71
| Professional | | $1,513.56 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |