- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.46 / $1,039.20 / $1,425.49
| Professional | | $1,001.46 | $1,039.20 | $1,425.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.08 / $1,376.57 / $2,251.73
| Professional | | $1,170.08 | $1,376.57 | $2,251.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,710.09 / $2,452.15
| Professional | | $250.00 | $1,710.09 | $2,452.15 |
- 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
- $1,048.33 / $1,480.01 / $2,537.19
| Professional | | $1,048.33 | $1,480.01 | $2,537.19 |