- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $4,593.68 / $5,095.72
| Facility | | $2,510.21 | $4,593.68 | $5,095.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.07 / $4,593.68 / $5,095.72
| Professional | | $1,983.07 | $4,593.68 | $5,095.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,263.27 / $3,388.78 / $3,388.78
| Facility | | $3,263.27 | $3,388.78 | $3,388.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $1,631.64 / $1,713.22
| Facility | | $1,631.64 | $1,631.64 | $1,713.22 |
- 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
- $1,054.29 / $1,506.13 / $3,765.32
| Professional | | $1,054.29 | $1,506.13 | $3,765.32 |