- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $10,000.00 / $10,964.78
| Facility | | $5,495.41 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,466.84 / $10,000.00
| Professional | | $4,073.80 | $4,466.84 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,413.10 / $7,413.10
| Facility | | $7,079.46 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $50.12
| Professional | | $21.38 | $25.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,606.93
| Facility | | $4,897.79 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $12,302.69
| Professional | | $2,290.87 | $3,311.31 | $12,302.69 |