- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,743.01 / $3,205.42 / $5,170.22
| Facility | | $2,743.01 | $3,205.42 | $5,170.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,069.31 / $4,098.84 / $4,657.78
| Professional | | $2,069.31 | $4,098.84 | $4,657.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.00 / $8,306.09 / $8,306.09
| Professional | | $1,517.00 | $8,306.09 | $8,306.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,067.94 / $4,067.94 / $4,067.94
| Facility | | $4,067.94 | $4,067.94 | $4,067.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,171.92 / $8,306.09 / $8,306.09
| Professional | | $4,171.92 | $8,306.09 | $8,306.09 |