- 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
- $1,092.29 / $1,225.96 / $1,461.49
| Professional | | $1,092.29 | $1,225.96 | $1,461.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.70 / $1,337.29 / $2,116.59
| Professional | | $1,136.70 | $1,337.29 | $2,116.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,468.92 / $2,416.67
| Professional | | $300.00 | $1,468.92 | $2,416.67 |
- 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
- $1,031.19 / $1,550.41 / $2,516.63
| Professional | | $1,031.19 | $1,550.41 | $2,516.63 |