- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,981.07 / $6,760.83
| Facility | | $1,479.11 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,023.29 / $2,344.23
| Professional | | $602.56 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,570.40 / $10,000.00
| Facility | | $1,096.48 | $2,570.40 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $2,238.72
| Professional | | $1,258.93 | $1,737.80 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $10,964.78
| Facility | | $5,128.61 | $8,128.31 | $10,964.78 |