- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,757.57 / $2,757.57 / $10,752.66
| Facility | | $2,757.57 | $2,757.57 | $10,752.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.02 / $1,711.43 / $1,711.43
| Professional | | $584.02 | $1,711.43 | $1,711.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.00 / $1,292.00 / $1,447.00
| Professional | | $1,077.00 | $1,292.00 | $1,447.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.59 / $776.31 / $1,267.77
| Professional | | $569.59 | $776.31 | $1,267.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $1,270.73 / $2,080.31
| Professional | | $743.60 | $1,270.73 | $2,080.31 |