- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.50 / $517.50 / $517.50
| Professional | | $517.50 | $517.50 | $517.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $250.00 / $425.00
| Professional | | $150.00 | $250.00 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.20 / $945.20 / $91,555.55
| Professional | | $945.20 | $945.20 | $91,555.55 |