- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,233.06 / $4,233.06 / $4,233.06
| Facility | | $4,233.06 | $4,233.06 | $4,233.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,233.06 / $4,233.06 / $10,154.87
| Professional | | $4,233.06 | $4,233.06 | $10,154.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $10,777.03 / $18,104.25
| Professional | | $1,092.81 | $10,777.03 | $18,104.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $1,374.52 / $17,868.38
| Professional | | $60.00 | $1,374.52 | $17,868.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,704.88 / $10,704.88 / $10,704.88
| Professional | | $10,704.88 | $10,704.88 | $10,704.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,037.72 / $6,507.39 / $9,406.79
| Professional | | $5,037.72 | $6,507.39 | $9,406.79 |