- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,849.10 / $2,160.82 / $3,485.32
| Facility | | $1,849.10 | $2,160.82 | $3,485.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.59 / $977.27 / $1,263.33
| Professional | | $792.59 | $977.27 | $1,263.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.30 / $2,225.30 / $2,225.30
| Professional | | $2,225.30 | $2,225.30 | $2,225.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61,755.25 / $61,755.25 / $61,755.25
| Facility | | $61,755.25 | $61,755.25 | $61,755.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.17 / $1,304.17 / $2,225.30
| Professional | | $1,304.17 | $1,304.17 | $2,225.30 |