- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,770.29 / $4,405.88 / $6,758.73
| Facility | | $3,770.29 | $4,405.88 | $6,758.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,844.28 / $5,637.52 / $6,406.28
| Professional | | $2,844.28 | $5,637.52 | $6,406.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,402.46 / $11,402.46 / $11,402.46
| Professional | | $11,402.46 | $11,402.46 | $11,402.46 |
- 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
- $5,242.08 / $5,242.08 / $5,242.08
| Facility | | $5,242.08 | $5,242.08 | $5,242.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,244.50 / $11,402.46 / $11,402.46
| Professional | | $6,244.50 | $11,402.46 | $11,402.46 |