- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,786.30 / $7,079.46
| Facility | | $1,174.90 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,000.00 / $2,630.27
| Professional | | $616.60 | $1,000.00 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,819.70 / $9,549.93
| Facility | | $1,096.48 | $1,819.70 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $1,995.26
| Professional | | $1,380.38 | $1,698.24 | $1,995.26 |
- 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 |