- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,079.46 / $11,220.18
| Facility | | $6,025.60 | $7,079.46 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,244.36 / $8,317.64
| Professional | | $3,715.35 | $7,244.36 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $31,622.78 / $31,622.78
| Professional | | $4,786.30 | $31,622.78 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $70.79
| Professional | | $50.12 | $50.12 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,000.00 / $10,000.00
| Facility | | $6,606.93 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $31,622.78 / $31,622.78
| Professional | | $8,912.51 | $31,622.78 | $31,622.78 |