- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $15,135.61
| Facility | | $5,888.44 | $7,943.28 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,606.93 / $7,943.28
| Professional | | $5,888.44 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,302.69 / $16,982.44 / $19,054.61
| Professional | | $12,302.69 | $16,982.44 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $12,302.69
| Professional | | $9,772.37 | $9,772.37 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,456.54 / $15,135.61
| Facility | | $5,128.61 | $6,456.54 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,000.00 / $16,982.44
| Professional | | $3,548.13 | $10,000.00 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $8,709.64 / $14,454.40
| Professional | | $3,548.13 | $8,709.64 | $14,454.40 |