- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,317.64 / $16,595.87
| Facility | | $6,760.83 | $8,317.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,317.64 / $13,489.63
| Professional | | $6,760.83 | $8,317.64 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,912.51 / $30,902.95
| Facility | | $6,606.93 | $8,912.51 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,912.51 / $18,620.87
| Professional | | $8,128.31 | $8,912.51 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $57,543.99
| Facility | | $10,000.00 | $10,000.00 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $22,387.21
| Professional | | $7,244.36 | $7,244.36 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,964.78 / $19,498.45
| Facility | | $6,606.93 | $10,964.78 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $12,022.64
| Professional | | $5,888.44 | $7,943.28 | $12,022.64 |