- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.64 / $7,838.38 / $14,860.56
| Facility | | $1,720.64 | $7,838.38 | $14,860.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.64 / $1,789.92 / $1,872.08
| Professional | | $1,720.64 | $1,789.92 | $1,872.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $2,465.07
| Professional | | $60.00 | $85.00 | $2,465.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $4,262.00 / $17,636.00
| Facility | | $3,085.00 | $4,262.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,524.28 / $3,155.36 / $4,130.63
| Professional | | $2,524.28 | $3,155.36 | $4,130.63 |