- 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
- $1,122.08 / $1,136.74 / $1,585.89
| Professional | | $1,122.08 | $1,136.74 | $1,585.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.01 / $1,376.48 / $2,269.65
| Professional | | $1,170.01 | $1,376.48 | $2,269.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,709.52 / $2,334.17
| Professional | | $300.00 | $1,709.52 | $2,334.17 |
- 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
- $1,126.53 / $1,617.97 / $2,296.94
| Professional | | $1,126.53 | $1,617.97 | $2,296.94 |