- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,495.41 / $7,762.47
| Facility | | $1,122.02 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $3,235.94
| Professional | | $1,000.00 | $1,122.02 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,715.35 / $10,715.19
| Professional | | $1,258.93 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $3,019.95
| Professional | | $1,071.52 | $1,621.81 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,187.76 / $2,511.89
| Professional | | $977.24 | $2,187.76 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,548.82 / $3,019.95
| Professional | | $954.99 | $1,548.82 | $3,019.95 |