- 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 / $3,090.30
| Professional | | $1,000.00 | $1,122.02 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,715.35 / $10,715.19
| Professional | | $1,174.90 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $3,019.95
| Professional | | $1,096.48 | $1,621.81 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,238.72 / $2,511.89
| Professional | | $1,047.13 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $63,095.73
| Facility | | $4,897.79 | $13,489.63 | $63,095.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $3,019.95
| Professional | | $912.01 | $1,445.44 | $3,019.95 |