- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,011.87 / $7,762.47
| Facility | | $1,949.84 | $5,011.87 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $7,762.47
| Facility | | $3,715.35 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.12 / $1,000.00 / $2,754.23
| Professional | | $9.12 | $1,000.00 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,090.30 / $9,120.11
| Facility | | $1,659.59 | $3,090.30 | $9,120.11 |