- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,157.10 / $6,026.49 / $9,244.79
| Facility | | $5,157.10 | $6,026.49 | $9,244.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.50 / $7,551.56 / $8,581.31
| Professional | | $3,890.50 | $7,551.56 | $8,581.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,256.18 / $11,256.18 / $11,256.18
| Professional | | $11,256.18 | $11,256.18 | $11,256.18 |
- 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
- $7,055.10 / $7,055.10 / $7,055.10
| Facility | | $7,055.10 | $7,055.10 | $7,055.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,737.35 / $11,256.18 / $11,256.18
| Professional | | $7,737.35 | $11,256.18 | $11,256.18 |