- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,440.48 / $4,020.47 / $6,167.50
| Facility | | $3,440.48 | $4,020.47 | $6,167.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,595.48 / $5,141.25 / $5,842.33
| Professional | | $2,595.48 | $5,141.25 | $5,842.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,396.14 / $10,396.14 / $10,396.14
| Professional | | $10,396.14 | $10,396.14 | $10,396.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,870.85 / $4,870.85 / $4,870.85
| Facility | | $4,870.85 | $4,870.85 | $4,870.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,701.50 / $10,396.14 / $10,396.14
| Professional | | $5,701.50 | $10,396.14 | $10,396.14 |