- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,666.54 / $7,582.20 / $29,150.50
| Facility | | $2,666.54 | $7,582.20 | $29,150.50 |
- 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
- $915.33 / $11,126.88 / $18,765.95
| Facility | | $915.33 | $11,126.88 | $18,765.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,411.99 / $4,549.32 / $6,173.47
| Professional | | $3,411.99 | $4,549.32 | $6,173.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,330.68 / $24,387.24 / $43,519.12
| Facility | | $11,330.68 | $24,387.24 | $43,519.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,719.53 / $13,814.77 / $18,728.03
| Professional | | $8,719.53 | $13,814.77 | $18,728.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,487.81 / $4,549.32 / $13,306.00
| Professional | | $3,487.81 | $4,549.32 | $13,306.00 |