- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,845.74 / $3,325.47 / $5,363.86
| Facility | | $2,845.74 | $3,325.47 | $5,363.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.81 / $4,250.20 / $4,829.78
| Professional | | $2,146.81 | $4,250.20 | $4,829.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.00 / $11,462.87 / $11,462.87
| Professional | | $1,544.00 | $11,462.87 | $11,462.87 |
- 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
- $4,176.81 / $4,176.81 / $4,176.81
| Facility | | $4,176.81 | $4,176.81 | $4,176.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,298.60 / $11,462.87 / $11,462.87
| Professional | | $4,298.60 | $11,462.87 | $11,462.87 |