- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,242.23 / $3,788.80 / $6,111.20
| Facility | | $3,242.23 | $3,788.80 | $6,111.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,445.92 / $2,946.54 / $5,151.14
| Professional | | $2,445.92 | $2,946.54 | $5,151.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.00 / $7,745.61 / $7,745.61
| Professional | | $1,457.00 | $7,745.61 | $7,745.61 |
- 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
- $5,854.00 / $5,854.00 / $5,854.00
| Facility | | $5,854.00 | $5,854.00 | $5,854.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,072.36 / $7,745.61 / $7,745.61
| Professional | | $6,072.36 | $7,745.61 | $7,745.61 |