- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.75 / $1,418.22 / $1,476.24
| Professional | | $1,165.75 | $1,418.22 | $1,476.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.04 / $1,481.22 / $3,052.93
| Professional | | $1,259.04 | $1,481.22 | $3,052.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,670.27 / $2,983.06
| Professional | | $250.00 | $1,670.27 | $2,983.06 |
- 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
- $1,098.52 / $1,723.58 / $2,661.01
| Professional | | $1,098.52 | $1,723.58 | $2,661.01 |