- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,495.41 / $7,762.47
| Facility | | $1,148.15 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,071.52 / $2,630.27
| Professional | | $707.95 | $1,071.52 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $6,165.95 / $15,488.17
| Professional | | $1,047.13 | $6,165.95 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,148.15 / $2,511.89
| Professional | | $891.25 | $1,148.15 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,000.00 / $2,187.76
| Professional | | $954.99 | $1,000.00 | $2,187.76 |
- 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
- $758.58 / $1,148.15 / $2,454.71
| Professional | | $758.58 | $1,148.15 | $2,454.71 |