- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,123.58 / $8,123.58 / $10,775.90
| Facility | | $8,123.58 | $8,123.58 | $10,775.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,123.58 / $8,123.58 / $10,154.48
| Professional | | $8,123.58 | $8,123.58 | $10,154.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.93 / $1,353.93 / $1,353.93
| Professional | | $1,353.93 | $1,353.93 | $1,353.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $10,777.03 / $17,925.00
| Professional | | $1,092.81 | $10,777.03 | $17,925.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,242.02 / $10,154.48 / $25,187.82
| Facility | | $2,242.02 | $10,154.48 | $25,187.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,338.26 / $6,507.39 / $10,905.53
| Professional | | $4,338.26 | $6,507.39 | $10,905.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,338.26 / $6,507.39 / $9,406.79
| Professional | | $4,338.26 | $6,507.39 | $9,406.79 |