- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,622.50 / $4,233.18 / $6,493.81
| Facility | | $3,622.50 | $4,233.18 | $6,493.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.80 / $5,295.48 / $6,017.59
| Professional | | $2,732.80 | $5,295.48 | $6,017.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,846.44 / $7,846.44 / $7,846.44
| Professional | | $7,846.44 | $7,846.44 | $7,846.44 |
- 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
- $5,219.25 / $5,219.25 / $5,219.25
| Facility | | $5,219.25 | $5,219.25 | $5,219.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,905.16 / $7,846.44 / $7,846.44
| Professional | | $5,905.16 | $7,846.44 | $7,846.44 |