- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,869.17 / $3,352.85 / $5,408.02
| Facility | | $2,869.17 | $3,352.85 | $5,408.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.20 / $3,159.06 / $4,334.22
| Professional | | $1,288.20 | $3,159.06 | $4,334.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.00 / $5,897.00 / $5,897.00
| Professional | | $1,336.00 | $5,897.00 | $5,897.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $55.00 / $70.00
| Professional | | $50.00 | $55.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,253.85 / $4,253.85 / $4,253.85
| Facility | | $4,253.85 | $4,253.85 | $4,253.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,006.48 / $5,897.00 / $5,897.00
| Professional | | $4,006.48 | $5,897.00 | $5,897.00 |