- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,491.18 / $5,248.30 / $8,465.32
| Facility | | $4,491.18 | $5,248.30 | $8,465.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.12 / $6,025.34 / $7,135.45
| Professional | | $3,388.12 | $6,025.34 | $7,135.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.00 / $13,549.56 / $13,549.56
| Professional | | $2,529.00 | $13,549.56 | $13,549.56 |
- 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
- $6,453.78 / $6,453.78 / $6,453.78
| Facility | | $6,453.78 | $6,453.78 | $6,453.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,220.17 / $13,549.56 / $13,549.56
| Professional | | $5,220.17 | $13,549.56 | $13,549.56 |