- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,727.03 / $4,355.33 / $6,681.19
| Facility | | $3,727.03 | $4,355.33 | $6,681.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.25 / $3,493.45 / $5,123.47
| Professional | | $2,714.25 | $3,493.45 | $5,123.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,747.35 / $7,747.35 / $7,747.35
| Professional | | $7,747.35 | $7,747.35 | $7,747.35 |
- 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
- $3,655.03 / $3,655.03 / $3,655.03
| Facility | | $3,655.03 | $3,655.03 | $3,655.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,552.19 / $7,747.35 / $7,747.35
| Professional | | $2,552.19 | $7,747.35 | $7,747.35 |