- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,570.40 / $6,760.83
| Facility | | $933.25 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,122.02 / $2,398.83
| Professional | | $645.65 | $1,122.02 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,677.35 / $14,125.38
| Facility | | $1,000.00 | $4,677.35 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,513.56 / $2,137.96
| Professional | | $1,412.54 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,481.54 / $14,791.08
| Facility | | $7,244.36 | $11,481.54 | $14,791.08 |