- 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
- $1,196.74 / $1,323.52 / $1,562.72
| Professional | | $1,196.74 | $1,323.52 | $1,562.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.35 / $1,462.78 / $2,325.86
| Professional | | $1,243.35 | $1,462.78 | $2,325.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,715.13 / $2,459.98
| Professional | | $150.00 | $1,715.13 | $2,459.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.29 / $1,573.36 / $2,574.42
| Professional | | $1,084.29 | $1,573.36 | $2,574.42 |