- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,128.31 / $15,848.93
| Facility | | $5,011.87 | $8,128.31 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,248.07 / $6,309.57
| Professional | | $5,011.87 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $6,025.60 / $12,302.69
| Facility | | $1,621.81 | $6,025.60 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,248.07 / $6,309.57
| Professional | | $3,890.45 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $10,000.00
| Facility | | $5,370.32 | $5,370.32 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $5,370.32
| Professional | | $3,715.35 | $4,677.35 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,897.79 / $8,128.31
| Facility | | $1,047.13 | $4,897.79 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $6,309.57
| Professional | | $5,248.07 | $5,248.07 | $6,309.57 |