- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $13,803.84
| Facility | | $2,691.53 | $2,691.53 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,128.61 / $7,079.46
| Professional | | $2,691.53 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $14,454.40 / $16,982.44
| Professional | | $10,000.00 | $14,454.40 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $10,964.78
| Professional | | $8,709.64 | $8,709.64 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,570.88 / $11,481.54
| Facility | | $2,691.53 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,912.51 / $15,135.61
| Professional | | $3,162.28 | $8,912.51 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,762.47 / $12,882.50
| Professional | | $3,162.28 | $7,762.47 | $12,882.50 |