- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.20 / $10,019.60 / $13,526.50
| Facility | | $5,475.20 | $10,019.60 | $13,526.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,325.41 / $4,325.41 / $4,325.41
| Professional | | $4,325.41 | $4,325.41 | $4,325.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,117.76 / $7,391.52 / $7,391.52
| Facility | | $7,117.76 | $7,391.52 | $7,391.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,558.88 / $3,558.88 / $3,736.82
| Facility | | $3,558.88 | $3,558.88 | $3,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $8,785.23
| Professional | | $2,299.58 | $3,285.12 | $8,785.23 |