- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,198.35 / $4,022.98 / $5,431.02
| Facility | | $2,198.35 | $4,022.98 | $5,431.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.70 / $1,736.70 / $1,736.70
| Professional | | $1,736.70 | $1,736.70 | $1,736.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,857.86 / $2,967.77 / $2,967.77
| Facility | | $2,857.86 | $2,967.77 | $2,967.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.93 / $1,428.93 / $1,500.38
| Facility | | $1,428.93 | $1,428.93 | $1,500.38 |
- 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
- $923.31 / $1,319.01 / $3,737.20
| Professional | | $923.31 | $1,319.01 | $3,737.20 |