- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,263.69 / $7,319.61 / $11,806.27
| Facility | | $6,263.69 | $7,319.61 | $11,806.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,725.29 / $5,734.58 / $9,951.54
| Professional | | $4,725.29 | $5,734.58 | $9,951.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,903.00 / $16,929.27 / $16,929.27
| Professional | | $3,903.00 | $16,929.27 | $16,929.27 |
- 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
- $7,634.97 / $7,634.97 / $7,634.97
| Facility | | $7,634.97 | $7,634.97 | $7,634.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,451.24 / $16,929.27 / $16,929.27
| Professional | | $4,451.24 | $16,929.27 | $16,929.27 |