- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,582.20 / $13,875.40 / $18,731.80
| Facility | | $7,582.20 | $13,875.40 | $18,731.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,856.86 / $10,235.96 / $10,235.96
| Facility | | $9,856.86 | $10,235.96 | $10,235.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,928.43 / $4,928.43 / $5,174.85
| Facility | | $4,928.43 | $4,928.43 | $5,174.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $4,549.32 / $12,889.74
| Professional | | $3,184.52 | $4,549.32 | $12,889.74 |