- 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
- $961.08 / $994.21 / $1,361.62
| Professional | | $961.08 | $994.21 | $1,361.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.40 / $1,320.47 / $2,148.31
| Professional | | $1,122.40 | $1,320.47 | $2,148.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,617.84 / $2,289.65
| Professional | | $250.00 | $1,617.84 | $2,289.65 |
- 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
- $1,048.38 / $1,571.35 / $2,732.77
| Professional | | $1,048.38 | $1,571.35 | $2,732.77 |