- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,867.15 / $7,838.38 / $14,860.56
| Facility | | $1,867.15 | $7,838.38 | $14,860.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,824.79 / $1,867.15 / $1,969.21
| Professional | | $1,824.79 | $1,867.15 | $1,969.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $2,823.68
| Professional | | $60.00 | $85.00 | $2,823.68 |
- 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
- $2,294.91 / $2,828.61 / $3,842.64
| Professional | | $2,294.91 | $2,828.61 | $3,842.64 |