- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,140.81 / $7,838.38 / $14,860.56
| Facility | | $1,140.81 | $7,838.38 | $14,860.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.60 / $1,140.81 / $1,186.75
| Professional | | $1,119.60 | $1,140.81 | $1,186.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $1,500.00
| Professional | | $60.00 | $85.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $4,262.00 / $17,636.00
| Facility | | $3,085.00 | $4,262.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.39 / $1,930.49 / $2,772.91
| Professional | | $1,544.39 | $1,930.49 | $2,772.91 |