- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,049.63 / $4,732.32 / $7,633.06
| Facility | | $4,049.63 | $4,732.32 | $7,633.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,055.02 / $5,450.38 / $6,433.93
| Professional | | $3,055.02 | $5,450.38 | $6,433.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.00 / $11,725.87 / $11,725.87
| Professional | | $2,607.00 | $11,725.87 | $11,725.87 |
- 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
- $6,109.92 / $6,109.92 / $6,109.92
| Facility | | $6,109.92 | $6,109.92 | $6,109.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,108.75 / $11,725.87 / $11,725.87
| Professional | | $6,108.75 | $11,725.87 | $11,725.87 |