- 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
- $1,250.52 / $1,738.67 / $1,906.38
| Professional | | $1,250.52 | $1,738.67 | $1,906.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.46 / $1,999.37 / $3,021.48
| Professional | | $1,699.46 | $1,999.37 | $3,021.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,498.81 / $3,435.54
| Professional | | $300.00 | $2,498.81 | $3,435.54 |
- 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
- $1,727.25 / $2,381.39 / $3,675.88
| Professional | | $1,727.25 | $2,381.39 | $3,675.88 |