- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $5,370.32
| Facility | | $2,884.03 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,691.53 / $3,630.78
| Professional | | $1,148.15 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,888.44 / $5,888.44
| Professional | | $1,348.96 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $70.79
| Professional | | $50.12 | $50.12 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,265.80 / $4,265.80
| Facility | | $3,162.28 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $5,888.44
| Professional | | $3,981.07 | $5,888.44 | $5,888.44 |