- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,981.07 / $6,760.83
| Facility | | $1,122.02 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $2,454.71
| Professional | | $660.69 | $1,000.00 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,862.09 / $8,912.51
| Facility | | $1,122.02 | $1,862.09 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $1,905.46
| Professional | | $1,479.11 | $1,737.80 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |