- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $8,912.51
| Facility | | $3,467.37 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $4,677.35
| Professional | | $3,467.37 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $9,549.93 / $11,220.18
| Professional | | $7,244.36 | $9,549.93 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $7,244.36
| Professional | | $5,754.40 | $5,754.40 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,801.89 / $8,912.51
| Facility | | $3,019.95 | $3,801.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,888.44 / $10,000.00
| Professional | | $2,089.30 | $5,888.44 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,128.61 / $8,511.38
| Professional | | $2,089.30 | $5,128.61 | $8,511.38 |