- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $4,304.56 / $5,496.04
| Facility | | $3,706.14 | $4,304.56 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.41 / $1,081.79 / $1,167.64
| Professional | | $765.41 | $1,081.79 | $1,167.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.72 / $1,219.67 / $1,915.06
| Professional | | $1,036.72 | $1,219.67 | $1,915.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,384.21 / $2,050.40
| Professional | | $250.00 | $1,384.21 | $2,050.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $5,979.00 / $9,764.00
| Facility | | $3,219.00 | $5,979.00 | $9,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.37 / $1,421.27 / $2,195.11
| Professional | | $785.37 | $1,421.27 | $2,195.11 |