- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $3,890.45
| Facility | | $2,089.30 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $2,137.96
| Professional | | $1,445.44 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $7,585.78 / $7,585.78
| Professional | | $1,288.25 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,495.41 / $5,495.41
| Facility | | $3,630.78 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,585.78 / $7,585.78
| Professional | | $3,388.44 | $7,585.78 | $7,585.78 |