- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,550.24 / $7,654.48 / $12,346.40
| Facility | | $6,550.24 | $7,654.48 | $12,346.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,092.16 / $6,536.68 / $7,428.05
| Professional | | $3,092.16 | $6,536.68 | $7,428.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,647.62 / $3,647.62 / $3,647.62
| Facility | | $3,647.62 | $3,647.62 | $3,647.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,804.60 / $8,804.60 / $8,804.60
| Professional | | $8,804.60 | $8,804.60 | $8,804.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $65.00 / $70.00
| Professional | | $50.00 | $65.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,018.72 / $3,647.62 / $3,647.62
| Facility | | $3,018.72 | $3,647.62 | $3,647.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,553.24 / $8,804.60 / $8,804.60
| Professional | | $4,553.24 | $8,804.60 | $8,804.60 |