- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,469.56 / $5,223.03 / $8,012.26
| Facility | | $4,469.56 | $5,223.03 | $8,012.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,255.00 / $4,242.93 / $6,144.20
| Professional | | $3,255.00 | $4,242.93 | $6,144.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,016.53 / $6,016.53 / $6,016.53
| Professional | | $6,016.53 | $6,016.53 | $6,016.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $65.00 / $70.00
| Professional | | $50.00 | $65.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,720.74 / $2,720.74 / $2,720.74
| Facility | | $2,720.74 | $2,720.74 | $2,720.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.89 / $6,016.53 / $6,016.53
| Professional | | $1,394.89 | $6,016.53 | $6,016.53 |