- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,570.40 / $6,760.83
| Facility | | $1,000.00 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $2,187.76
| Professional | | $676.08 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,737.80 / $15,848.93
| Facility | | $758.58 | $1,737.80 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $1,995.26
| Professional | | $1,096.48 | $1,621.81 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $9,120.11 / $14,125.38
| Facility | | $5,248.07 | $9,120.11 | $14,125.38 |