- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,981.07 / $6,760.83
| Facility | | $1,000.00 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $724.44 / $1,995.26
| Professional | | $416.87 | $724.44 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,949.84 / $7,079.46
| Facility | | $891.25 | $1,949.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $1,513.56
| Professional | | $933.25 | $1,318.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,754.40 / $7,585.78
| Facility | | $3,311.31 | $5,754.40 | $7,585.78 |