- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,011.87 / $12,589.25
| Facility | | $2,344.23 | $5,011.87 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,495.41 / $10,715.19
| Facility | | $4,168.69 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $954.99 / $7,943.28
| Facility | | $416.87 | $954.99 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $1,348.96
| Professional | | $933.25 | $1,000.00 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $8,128.31
| Facility | | $3,630.78 | $5,011.87 | $8,128.31 |