- 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
- $870.96 / $1,047.13 / $1,819.70
| Professional | | $870.96 | $1,047.13 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,659.59
| Professional | | $707.95 | $1,047.13 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $2,691.53
| Professional | | $812.83 | $1,096.48 | $2,691.53 |
- 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
- $3,311.31 / $10,000.00 / $26,915.35
| Facility | | $3,311.31 | $10,000.00 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $2,344.23
| Professional | | $758.58 | $1,047.13 | $2,344.23 |