- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.55 / $1,071.89 / $1,435.76
| Professional | | $1,045.55 | $1,071.89 | $1,435.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.56 / $1,278.30 / $2,040.13
| Professional | | $1,086.56 | $1,278.30 | $2,040.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,391.49 / $2,162.04
| Professional | | $300.00 | $1,391.49 | $2,162.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.68 / $1,491.62 / $2,039.25
| Professional | | $950.68 | $1,491.62 | $2,039.25 |