- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,753.25 / $5,038.45 / $5,589.10
| Facility | | $2,753.25 | $5,038.45 | $5,589.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.07 / $5,038.45 / $5,589.10
| Professional | | $2,175.07 | $5,038.45 | $5,589.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,156.41 / $1,156.41 / $1,156.41
| Facility | | $1,156.41 | $1,156.41 | $1,156.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.41 / $1,156.41 / $1,156.41
| Professional | | $1,156.41 | $1,156.41 | $1,156.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,789.61 / $1,789.61 / $1,879.09
| Facility | | $1,789.61 | $1,789.61 | $1,879.09 |
- 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
- $1,156.36 / $1,651.95 / $4,680.53
| Professional | | $1,156.36 | $1,651.95 | $4,680.53 |