- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,310.06 / $5,036.64 / $8,123.93
| Facility | | $4,310.06 | $5,036.64 | $8,123.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.48 / $5,800.31 / $6,847.68
| Professional | | $3,251.48 | $5,800.31 | $6,847.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.00 / $12,919.80 / $12,919.80
| Professional | | $2,711.00 | $12,919.80 | $12,919.80 |
- 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
- $6,773.97 / $6,773.97 / $6,773.97
| Facility | | $6,773.97 | $6,773.97 | $6,773.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,448.13 / $12,919.80 / $12,919.80
| Professional | | $6,448.13 | $12,919.80 | $12,919.80 |