- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,037.51 / $6,645.94 / $12,065.76
| Facility | | $2,037.51 | $6,645.94 | $12,065.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,142.64 / $3,859.17 / $9,251.04
| Professional | | $3,142.64 | $3,859.17 | $9,251.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,859.17 / $5,409.35
| Facility | | $3,859.17 | $3,859.17 | $5,409.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.00 / $1,050.00 / $3,983.66
| Professional | | $1,050.00 | $1,050.00 | $3,983.66 |