- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $11,220.18 / $21,877.62
| Facility | | $5,128.61 | $11,220.18 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $7,244.36
| Professional | | $5,128.61 | $5,128.61 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $10,000.00 / $16,595.87
| Facility | | $7,762.47 | $10,000.00 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,606.93
| Facility | | $4,897.79 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,413.10
| Professional | | $6,606.93 | $6,606.93 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,128.61 / $5,128.61
| Professional | | $4,570.88 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |