- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,073.80 / $7,762.47
| Facility | | $2,137.96 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,187.76 / $2,511.89
| Professional | | $1,000.00 | $2,187.76 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $16,218.10 / $20,417.38
| Professional | | $812.83 | $16,218.10 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $5,248.07
| Professional | | $2,754.23 | $2,754.23 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $57,543.99
| Facility | | $9,120.11 | $25,703.96 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,778.28 / $20,417.38
| Professional | | $776.25 | $1,778.28 | $20,417.38 |