- 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
- $975.46 / $989.05 / $1,291.75
| Professional | | $975.46 | $989.05 | $1,291.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.71 / $1,237.30 / $1,877.42
| Professional | | $1,051.71 | $1,237.30 | $1,877.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,348.69 / $2,000.61
| Professional | | $350.00 | $1,348.69 | $2,000.61 |
- 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
- $944.81 / $1,386.76 / $2,045.22
| Professional | | $944.81 | $1,386.76 | $2,045.22 |