- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $20,892.96 / $40,738.03
| Facility | | $2,691.53 | $20,892.96 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,128.61 / $7,244.36
| Professional | | $2,691.53 | $5,128.61 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,754.40 / $30,902.95
| Facility | | $3,890.45 | $5,754.40 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,964.78 / $36,307.81
| Professional | | $9,332.54 | $10,964.78 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $6,456.54
| Professional | | $4,570.88 | $4,570.88 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,165.95 / $6,760.83
| Professional | | $4,570.88 | $6,165.95 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,760.83 / $7,585.78
| Facility | | $3,162.28 | $6,760.83 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $11,481.54
| Professional | | $2,630.27 | $3,162.28 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,570.88 / $4,570.88
| Professional | | $2,041.74 | $4,570.88 | $4,570.88 |