- 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
- $676.08 / $1,000.00 / $3,801.89
| Professional | | $676.08 | $1,000.00 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $8,912.51
| Facility | | $1,096.48 | $1,862.09 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $1,905.46
| Professional | | $1,513.56 | $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 |