- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $9,332.54
| Facility | | $3,630.78 | $3,630.78 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $4,897.79
| Professional | | $3,467.37 | $3,801.89 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $10,000.00 / $11,748.98
| Professional | | $7,585.78 | $10,000.00 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,585.78
| Professional | | $6,025.60 | $6,025.60 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,981.07 / $9,332.54
| Facility | | $3,162.28 | $3,981.07 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,165.95 / $10,471.29
| Professional | | $2,187.76 | $6,165.95 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $8,912.51
| Professional | | $2,187.76 | $5,370.32 | $8,912.51 |