- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $5,781.74 / $7,805.35
| Facility | | $3,159.42 | $5,781.74 | $7,805.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $3,633.33
| Professional | | $2,495.94 | $2,495.94 | $3,633.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,107.25 / $4,265.22 / $4,265.22
| Facility | | $4,107.25 | $4,265.22 | $4,265.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,053.62 / $2,053.62 / $2,156.30
| Facility | | $2,053.62 | $2,053.62 | $2,156.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,895.65 / $4,739.13
| Professional | | $1,326.96 | $1,895.65 | $4,739.13 |