- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,073.80 / $7,762.47
| Facility | | $1,288.25 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $3,388.44
| Professional | | $1,122.02 | $1,288.25 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $17,782.79
| Professional | | $1,230.27 | $1,819.70 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $3,388.44
| Professional | | $1,230.27 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,511.89 / $2,818.38
| Professional | | $1,202.26 | $2,511.89 | $2,818.38 |
- 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
- $1,000.00 / $1,621.81 / $3,388.44
| Professional | | $1,000.00 | $1,621.81 | $3,388.44 |