- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,158.71 / $3,061.34 / $7,364.46
| Facility | | $2,158.71 | $3,061.34 | $7,364.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.73 / $1,651.92 / $2,966.57
| Professional | | $1,313.73 | $1,651.92 | $2,966.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,754.89 / $2,798.80 / $5,798.79
| Facility | | $1,754.89 | $2,798.80 | $5,798.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.72 / $1,537.80 / $2,625.79
| Professional | | $1,300.72 | $1,537.80 | $2,625.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.88 / $1,264.72 / $1,724.06
| Facility | | $140.88 | $1,264.72 | $1,724.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,524.00 / $7,524.00 / $7,524.00
| Professional | | $7,524.00 | $7,524.00 | $7,524.00 |