- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,595.71 / $5,370.45 / $8,662.35
| Facility | | $4,595.71 | $5,370.45 | $8,662.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,466.98 / $6,163.83 / $7,301.52
| Professional | | $3,466.98 | $6,163.83 | $7,301.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,956.00 / $12,098.52 / $12,098.52
| Professional | | $2,956.00 | $12,098.52 | $12,098.52 |
- 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
- $6,610.74 / $6,610.74 / $6,610.74
| Facility | | $6,610.74 | $6,610.74 | $6,610.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,936.84 / $12,098.52 / $12,098.52
| Professional | | $5,936.84 | $12,098.52 | $12,098.52 |