- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,786.30 / $7,943.28
| Facility | | $3,388.44 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $2,630.27
| Professional | | $1,000.00 | $1,122.02 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $1,819.70
| Professional | | $912.01 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $6,760.83
| Facility | | $1,949.84 | $1,949.84 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,737.80
| Professional | | $831.76 | $1,096.48 | $1,737.80 |