- 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
- $903.84 / $920.52 / $1,284.81
| Professional | | $903.84 | $920.52 | $1,284.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.11 / $1,222.49 / $2,033.62
| Professional | | $1,039.11 | $1,222.49 | $2,033.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,497.35 / $2,167.96
| Professional | | $250.00 | $1,497.35 | $2,167.96 |
- 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
- $1,031.50 / $1,278.88 / $2,093.75
| Professional | | $1,031.50 | $1,278.88 | $2,093.75 |