- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,279.00 / $4,170.57 / $5,630.27
| Facility | | $2,279.00 | $4,170.57 | $5,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.25 / $1,709.25 / $1,709.25
| Professional | | $1,709.25 | $1,709.25 | $1,709.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,962.70 / $3,076.65 / $3,076.65
| Facility | | $2,962.70 | $3,076.65 | $3,076.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.35 / $1,481.35 / $1,555.42
| Facility | | $1,481.35 | $1,481.35 | $1,555.42 |
- 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
- $957.18 / $1,367.40 / $3,874.30
| Professional | | $957.18 | $1,367.40 | $3,874.30 |