- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.09 / $1,319.45 / $2,024.06
| Facility | | $1,129.09 | $1,319.45 | $2,024.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.28 / $1,068.28 / $1,552.15
| Professional | | $822.28 | $1,068.28 | $1,552.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.75 / $2,243.75 / $2,243.75
| Professional | | $2,243.75 | $2,243.75 | $2,243.75 |
- 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
- $1,421.97 / $1,421.97 / $1,421.97
| Facility | | $1,421.97 | $1,421.97 | $1,421.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.41 / $2,243.75 / $2,243.75
| Professional | | $780.41 | $2,243.75 | $2,243.75 |