- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $6,606.93 / $8,128.31
| Facility | | $1,148.15 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $2,818.38
| Professional | | $645.65 | $1,000.00 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $8,128.31
| Facility | | $1,148.15 | $1,905.46 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $1,949.84
| Professional | | $1,445.44 | $1,659.59 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |