- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $4,813.58 / $6,147.27
| Facility | | $3,706.14 | $4,813.58 | $6,147.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.01 / $1,127.64 / $1,576.50
| Professional | | $1,116.01 | $1,127.64 | $1,576.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.47 / $1,368.79 / $2,251.60
| Professional | | $1,163.47 | $1,368.79 | $2,251.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,709.52 / $2,320.63
| Professional | | $300.00 | $1,709.52 | $2,320.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.27 / $1,608.58 / $2,284.66
| Professional | | $1,173.27 | $1,608.58 | $2,284.66 |