- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,737.50 / $7,321.05 / $17,839.08
| Facility | | $5,737.50 | $7,321.05 | $17,839.08 |
- 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
- $49.76 / $1,170.00 / $1,170.00
| Professional | | $49.76 | $1,170.00 | $1,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $744.12
| Professional | | $198.37 | $198.37 | $744.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $1,737.96
| Facility | | $1,448.30 | $1,448.30 | $1,737.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,204.94 / $3,204.94 / $3,204.94
| Professional | | $3,204.94 | $3,204.94 | $3,204.94 |