- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $5,495.41
| Facility | | $4,073.80 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $5,495.41
| Professional | | $3,311.31 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $6,606.93
| Facility | | $2,137.96 | $2,137.96 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $10,715.19
| Professional | | $6,606.93 | $6,606.93 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,073.80 / $5,754.40
| Facility | | $2,884.03 | $4,073.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,041.74 / $5,370.32
| Professional | | $1,174.90 | $2,041.74 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $10,232.93 / $19,952.62
| Facility | | $5,370.32 | $10,232.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $7,244.36
| Professional | | $1,000.00 | $1,380.38 | $7,244.36 |