- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.54 / $5,831.68 / $11,124.39
| Facility | | $3,060.54 | $5,831.68 | $11,124.39 |
- 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
- $3,161.86 / $7,130.48 / $11,984.45
| Facility | | $3,161.86 | $7,130.48 | $11,984.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,859.17 / $9,251.04
| Professional | | $3,859.17 | $3,859.17 | $9,251.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $50.00 / $75.00
| Professional | | $30.00 | $50.00 | $75.00 |