- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,769.84 / $12,847.62 / $13,343.17
| Facility | | $2,769.84 | $12,847.62 | $13,343.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.76 / $1,163.65 / $1,362.74
| Professional | | $1,077.76 | $1,163.65 | $1,362.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.00 / $1,248.00 / $1,248.00
| Facility | | $1,248.00 | $1,248.00 | $1,248.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.33 / $1,167.81 / $1,812.31
| Professional | | $898.33 | $1,167.81 | $1,812.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,485.02 / $7,485.02 / $7,485.02
| Facility | | $7,485.02 | $7,485.02 | $7,485.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.43 / $745.43 / $1,005.69
| Professional | | $745.43 | $745.43 | $1,005.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.36 / $1,130.86 / $2,329.59
| Professional | | $875.36 | $1,130.86 | $2,329.59 |