- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,244.36
| Facility | | $6,606.93 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $4,365.16
| Professional | | $1,548.82 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,819.70 / $3,235.94
| Professional | | $1,000.00 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,791.08 / $14,791.08 / $14,791.08
| Professional | | $14,791.08 | $14,791.08 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $2,818.38
| Professional | | $977.24 | $1,513.56 | $2,818.38 |