- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $17,782.79 / $33,884.42
| Facility | | $5,011.87 | $17,782.79 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,754.40 / $7,943.28
| Professional | | $5,011.87 | $5,754.40 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,585.78 / $10,000.00
| Professional | | $7,079.46 | $7,585.78 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $18,197.01 / $40,738.03
| Facility | | $4,677.35 | $18,197.01 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,548.13 / $9,772.37
| Professional | | $3,235.94 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,456.54 / $12,302.69
| Facility | | $5,011.87 | $6,456.54 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,244.36 / $8,709.64
| Facility | | $6,456.54 | $7,244.36 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,365.16 / $7,244.36
| Professional | | $3,019.95 | $4,365.16 | $7,244.36 |