- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.33 / $4,736.00 / $7,448.34
| Facility | | $1,452.33 | $4,736.00 | $7,448.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.19 / $565.11 / $565.11
| Professional | | $492.19 | $565.11 | $565.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,732.57 / $1,732.57 / $1,732.57
| Facility | | $1,732.57 | $1,732.57 | $1,732.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.07 / $647.24 / $1,024.46
| Professional | | $503.07 | $647.24 | $1,024.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.88 / $747.88 / $1,295.98
| Professional | | $475.88 | $747.88 | $1,295.98 |