- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,786.30 / $7,079.46
| Facility | | $1,148.15 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $831.76 / $1,995.26
| Professional | | $478.63 | $831.76 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,951.21 / $10,232.93
| Facility | | $1,000.00 | $2,951.21 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $1,778.28
| Professional | | $1,096.48 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $10,964.78
| Facility | | $4,365.16 | $6,606.93 | $10,964.78 |