- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,237.34 / $2,237.34 / $2,237.34
| Facility | | $2,237.34 | $2,237.34 | $2,237.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,460.89
| Professional | | $1,448.30 | $1,448.30 | $2,460.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $1,477.27
| Facility | | $1,448.30 | $1,448.30 | $1,477.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,500.00
| Professional | | $30.00 | $55.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,849.00 / $2,849.00 / $2,849.00
| Professional | | $2,849.00 | $2,849.00 | $2,849.00 |