- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.44 / $2,806.00 / $3,771.00
| Facility | | $1,645.44 | $2,806.00 | $3,771.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.41 / $1,560.41 / $2,921.00
| Professional | | $1,560.41 | $1,560.41 | $2,921.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $561.00 / $686.40 / $728.00
| Facility | | $561.00 | $686.40 | $728.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.34 / $1,046.00 / $1,524.33
| Facility | | $799.34 | $1,046.00 | $1,524.33 |