- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,073.80 / $7,762.47
| Facility | | $1,047.13 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $977.24 / $2,511.89
| Professional | | $870.96 | $977.24 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,398.83 / $6,456.54
| Professional | | $977.24 | $2,398.83 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,905.46 / $2,290.87
| Professional | | $1,000.00 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $13,489.63 / $26,915.35
| Facility | | $3,311.31 | $13,489.63 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,258.93 / $2,754.23
| Professional | | $724.44 | $1,258.93 | $2,754.23 |