- 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
- $1,101.02 / $1,142.78 / $1,544.49
| Professional | | $1,101.02 | $1,142.78 | $1,544.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.71 / $1,532.60 / $2,425.26
| Professional | | $1,302.71 | $1,532.60 | $2,425.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,897.98 / $2,614.21
| Professional | | $250.00 | $1,897.98 | $2,614.21 |
- 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
- $1,156.70 / $1,607.41 / $2,761.42
| Professional | | $1,156.70 | $1,607.41 | $2,761.42 |