- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.56 / $4,456.38 / $4,897.12
| Facility | | $2,448.56 | $4,456.38 | $4,897.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.36 / $4,456.38 / $4,897.12
| Professional | | $1,934.36 | $4,456.38 | $4,897.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.13 / $3,305.56 / $3,305.56
| Facility | | $3,183.13 | $3,305.56 | $3,305.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $3,672.84
| Professional | | $1,028.40 | $1,469.14 | $3,672.84 |