- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,927.32 / $5,757.97 / $8,832.87
| Facility | | $4,927.32 | $5,757.97 | $8,832.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,717.15 / $7,210.56 / $8,193.81
| Professional | | $3,717.15 | $7,210.56 | $8,193.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,732.74 / $10,732.74 / $10,732.74
| Professional | | $10,732.74 | $10,732.74 | $10,732.74 |
- 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
- $6,613.14 / $6,613.14 / $6,613.14
| Facility | | $6,613.14 | $6,613.14 | $6,613.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,901.09 / $10,732.74 / $10,732.74
| Professional | | $6,901.09 | $10,732.74 | $10,732.74 |