- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,699.65 / $6,907.00 / $9,716.79
| Facility | | $2,699.65 | $6,907.00 | $9,716.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.55 / $1,050.45 / $1,128.06
| Professional | | $1,027.55 | $1,050.45 | $1,128.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.38 / $1,467.30 / $1,724.89
| Professional | | $1,053.38 | $1,467.30 | $1,724.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,319.79 / $7,319.79 / $7,319.79
| Facility | | $7,319.79 | $7,319.79 | $7,319.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.94 / $1,349.22 / $2,653.05
| Professional | | $1,026.94 | $1,349.22 | $2,653.05 |