- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,581.10 / $3,513.71 / $12,807.60
| Facility | | $2,581.10 | $3,513.71 | $12,807.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.00 / $2,897.65 / $3,165.50
| Professional | | $1,461.00 | $2,897.65 | $3,165.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,435.00 / $2,435.00 / $2,435.00
| Facility | | $2,435.00 | $2,435.00 | $2,435.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,582.75 / $1,582.75 / $1,582.75
| Facility | | $1,582.75 | $1,582.75 | $1,582.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.70 / $1,217.50 / $3,409.00
| Professional | | $1,022.70 | $1,217.50 | $3,409.00 |