- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $8,128.31
| Facility | | $3,715.35 | $3,715.35 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $4,570.88
| Professional | | $1,995.26 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,025.60 / $10,000.00
| Facility | | $4,570.88 | $6,025.60 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,630.78 / $4,786.30
| Professional | | $1,862.09 | $3,630.78 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,025.60 / $20,892.96
| Facility | | $2,398.83 | $6,025.60 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,760.83 / $7,943.28
| Professional | | $5,011.87 | $6,760.83 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $6,456.54
| Professional | | $1,778.28 | $2,187.76 | $6,456.54 |