- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.83 / $1,909.29 / $1,947.08
| Professional | | $1,373.83 | $1,909.29 | $1,947.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.47 / $2,062.90 / $3,363.71
| Professional | | $1,753.47 | $2,062.90 | $3,363.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,376.25 / $3,677.94
| Professional | | $300.00 | $2,376.25 | $3,677.94 |
- 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
- $1,275.45 / $2,455.69 / $3,799.34
| Professional | | $1,275.45 | $2,455.69 | $3,799.34 |