- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,437.98 / $6,291.51 / $6,979.10
| Facility | | $3,437.98 | $6,291.51 | $6,979.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,716.01 / $6,291.51 / $6,979.10
| Professional | | $2,716.01 | $6,291.51 | $6,979.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Facility | | $2,059.51 | $2,059.51 | $2,059.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Professional | | $2,059.51 | $2,059.51 | $2,059.51 |
- 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
- $1,443.95 / $2,062.79 / $5,844.57
| Professional | | $1,443.95 | $2,062.79 | $5,844.57 |