- 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
- $1,053.70 / $1,092.89 / $1,469.67
| Professional | | $1,053.70 | $1,092.89 | $1,469.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.88 / $1,466.92 / $2,317.52
| Professional | | $1,246.88 | $1,466.92 | $2,317.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,769.10 / $2,484.10
| Professional | | $250.00 | $1,769.10 | $2,484.10 |
- 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
- $1,087.82 / $1,706.79 / $2,638.95
| Professional | | $1,087.82 | $1,706.79 | $2,638.95 |