- 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
- $1,334.72 / $1,387.78 / $1,871.34
| Professional | | $1,334.72 | $1,387.78 | $1,871.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.61 / $1,859.54 / $2,938.88
| Professional | | $1,580.61 | $1,859.54 | $2,938.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $2,273.08 / $3,143.74
| Professional | | $250.00 | $2,273.08 | $3,143.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.25 / $2,167.42 / $3,350.40
| Professional | | $1,446.25 | $2,167.42 | $3,350.40 |