- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,883.83 / $4,538.56 / $7,320.54
| Facility | | $3,883.83 | $4,538.56 | $7,320.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,929.94 / $4,262.27 / $6,170.50
| Professional | | $2,929.94 | $4,262.27 | $6,170.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.00 / $8,992.00 / $8,992.00
| Professional | | $1,647.00 | $8,992.00 | $8,992.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $55.00 / $70.00
| Professional | | $50.00 | $55.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,694.18 / $5,694.18 / $5,694.18
| Facility | | $5,694.18 | $5,694.18 | $5,694.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,450.54 / $8,992.00 / $8,992.00
| Professional | | $5,450.54 | $8,992.00 | $8,992.00 |