- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,786.30 / $7,079.46
| Facility | | $1,412.54 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,023.29 / $2,187.76
| Professional | | $588.84 | $1,023.29 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,454.71 / $10,000.00
| Facility | | $1,230.27 | $2,454.71 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,137.96
| Professional | | $1,258.93 | $1,778.28 | $2,137.96 |
- 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 |