- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.83 / $1,574.33 / $1,751.70
| Professional | | $1,126.83 | $1,574.33 | $1,751.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.63 / $1,841.92 / $2,735.88
| Professional | | $1,565.63 | $1,841.92 | $2,735.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,253.54 / $3,125.68
| Professional | | $300.00 | $2,253.54 | $3,125.68 |
- 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
- $1,380.88 / $2,166.61 / $3,341.85
| Professional | | $1,380.88 | $2,166.61 | $3,341.85 |