- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $4,711.60 / $6,360.67
| Facility | | $2,574.65 | $4,711.60 | $6,360.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.97 / $2,033.97 / $2,960.85
| Professional | | $2,033.97 | $2,033.97 | $2,960.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,347.05 / $3,475.78 / $3,475.78
| Facility | | $3,347.05 | $3,475.78 | $3,475.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.52 / $1,673.52 / $1,757.20
| Facility | | $1,673.52 | $1,673.52 | $1,757.20 |
- 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
- $1,081.34 / $1,544.79 / $3,861.98
| Professional | | $1,081.34 | $1,544.79 | $3,861.98 |