- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,489.63 / $6,386.02 / $8,621.12
| Facility | | $3,489.63 | $6,386.02 | $8,621.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,756.81 / $2,756.81 / $2,756.81
| Professional | | $2,756.81 | $2,756.81 | $2,756.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.52 / $4,711.00 / $4,711.00
| Facility | | $4,536.52 | $4,711.00 | $4,711.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,268.26 / $2,268.26 / $2,381.67
| Facility | | $2,268.26 | $2,268.26 | $2,381.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $2,093.78 / $5,599.29
| Professional | | $1,465.64 | $2,093.78 | $5,599.29 |