- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.80 / $9,965.95 / $10,951.60
| Facility | | $5,475.80 | $9,965.95 | $10,951.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,325.88 / $9,965.95 / $10,951.60
| Professional | | $4,325.88 | $9,965.95 | $10,951.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,118.54 / $7,392.33 / $7,392.33
| Facility | | $7,118.54 | $7,392.33 | $7,392.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $9,347.03
| Professional | | $2,299.84 | $3,285.48 | $9,347.03 |