- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.40 / $1,721.16 / $1,832.39
| Professional | | $1,085.40 | $1,721.16 | $1,832.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.74 / $1,896.16 / $3,049.57
| Professional | | $1,611.74 | $1,896.16 | $3,049.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $2,369.32 / $3,295.70
| Professional | | $250.00 | $2,369.32 | $3,295.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.96 / $2,284.46 / $3,524.61
| Professional | | $1,408.96 | $2,284.46 | $3,524.61 |