- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,073.80 / $7,762.47
| Facility | | $1,071.52 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,071.52 / $2,951.21
| Professional | | $1,023.29 | $1,071.52 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $7,943.28
| Professional | | $1,023.29 | $1,513.56 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,348.96 / $2,754.23
| Professional | | $954.99 | $1,348.96 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,137.96 / $2,398.83
| Professional | | $1,000.00 | $2,137.96 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $14,125.38 / $33,884.42
| Facility | | $4,073.80 | $14,125.38 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,380.38 / $2,818.38
| Professional | | $870.96 | $1,380.38 | $2,818.38 |