- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,220.18 / $20,417.38
| Facility | | $5,370.32 | $11,220.18 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,073.80 / $5,495.41
| Professional | | $3,630.78 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Professional | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $10,000.00 / $12,302.69
| Facility | | $4,897.79 | $10,000.00 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,495.41 / $7,413.10
| Facility | | $4,365.16 | $5,495.41 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $27,542.29
| Professional | | $2,290.87 | $3,311.31 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,495.41 / $6,606.93
| Facility | | $2,290.87 | $5,495.41 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $7,079.46
| Professional | | $2,290.87 | $3,311.31 | $7,079.46 |