- 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
- $1,322.53 / $1,833.02 / $1,907.47
| Professional | | $1,322.53 | $1,833.02 | $1,907.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.14 / $2,000.17 / $3,185.44
| Professional | | $1,700.14 | $2,000.17 | $3,185.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,641.28 / $3,436.27
| Professional | | $300.00 | $2,641.28 | $3,436.27 |
- 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
- $1,518.10 / $2,381.90 / $3,676.68
| Professional | | $1,518.10 | $2,381.90 | $3,676.68 |