- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $10,000.00 / $11,220.18
| Professional | | $5,623.41 | $10,000.00 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $13,803.84
| Professional | | $8,511.38 | $8,511.38 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $15,848.93
| Facility | | $2,630.27 | $2,630.27 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $10,715.19 / $19,952.62
| Professional | | $1,230.27 | $10,715.19 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,778.28 / $7,762.47
| Facility | | $588.84 | $1,778.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,495.41 / $8,709.64
| Professional | | $3,311.31 | $5,495.41 | $8,709.64 |