- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,908.90 / $11,176.20 / $30,253.00
| Facility | | $6,908.90 | $11,176.20 | $30,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $2,666.54 / $2,666.54
| Professional | | $2,666.54 | $2,666.54 | $2,666.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,225.43 / $19,844.65 / $31,436.71
| Facility | | $5,225.43 | $19,844.65 | $31,436.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,975.06 / $7,236.45 / $35,051.55
| Professional | | $4,975.06 | $7,236.45 | $35,051.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,064.82 / $12,321.08 / $22,177.94
| Facility | | $5,064.82 | $12,321.08 | $22,177.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,080.07 / $7,582.20 / $13,843.35
| Facility | | $5,080.07 | $7,582.20 | $13,843.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $3,184.52 / $37,759.36
| Professional | | $3,184.52 | $3,184.52 | $37,759.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $3,184.52 / $4,549.32
| Professional | | $3,184.52 | $3,184.52 | $4,549.32 |