- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.23 / $1,818.58 / $2,789.75
| Facility | | $1,556.23 | $1,818.58 | $2,789.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.33 / $1,456.35 / $2,139.32
| Professional | | $1,133.33 | $1,456.35 | $2,139.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,641.06 / $3,641.06 / $3,641.06
| Professional | | $3,641.06 | $3,641.06 | $3,641.06 |
- 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
- $1,707.88 / $1,707.88 / $1,707.88
| Facility | | $1,707.88 | $1,707.88 | $1,707.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.07 / $3,641.06 / $3,641.06
| Professional | | $1,064.07 | $3,641.06 | $3,641.06 |