- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,754.40 / $8,511.38
| Facility | | $5,248.07 | $5,754.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,754.40 / $6,025.60
| Professional | | $5,128.61 | $5,754.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $12,302.69 / $14,791.08
| Professional | | $10,000.00 | $12,302.69 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $17,378.01
| Professional | | $7,413.10 | $10,000.00 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,511.38 / $16,982.44
| Facility | | $5,754.40 | $8,511.38 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $10,471.29 / $12,302.69
| Professional | | $5,495.41 | $10,471.29 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $10,471.29 / $14,125.38
| Professional | | $5,495.41 | $10,471.29 | $14,125.38 |