- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,981.07 / $6,760.83
| Facility | | $1,288.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $933.25 / $2,137.96
| Professional | | $537.03 | $933.25 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,454.71 / $10,000.00
| Facility | | $1,047.13 | $2,454.71 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,584.89 / $1,949.84
| Professional | | $1,148.15 | $1,584.89 | $1,949.84 |
- 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 |