- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,981.07 / $6,760.83
| Facility | | $1,621.81 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,148.15 / $2,951.21
| Professional | | $660.69 | $1,148.15 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,884.03 / $10,000.00
| Facility | | $1,380.38 | $2,884.03 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $2,454.71
| Professional | | $1,584.89 | $2,137.96 | $2,454.71 |
- 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 |