- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,981.07
| Professional | | $2,137.96 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,548.13
| Professional | | $2,691.53 | $2,691.53 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,715.35
| Professional | | $2,630.27 | $2,630.27 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,244.36 / $10,000.00
| Professional | | $3,388.44 | $7,244.36 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,630.27 / $3,890.45
| Professional | | $1,698.24 | $2,630.27 | $3,890.45 |