- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,492.06 / $18,659.80 / $53,075.40
| Facility | | $8,492.06 | $18,659.80 | $53,075.40 |
- 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
- $12,472.72 / $13,860.26 / $29,570.58
| Facility | | $12,472.72 | $13,860.26 | $29,570.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,032.88 / $4,928.43 / $4,928.43
| Professional | | $3,032.88 | $4,928.43 | $4,928.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,691.18 / $27,718.51 / $33,261.97
| Facility | | $13,691.18 | $27,718.51 | $33,261.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,582.20 / $11,004.81 / $24,976.52
| Professional | | $7,582.20 | $11,004.81 | $24,976.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $4,549.32 / $4,549.32
| Professional | | $3,184.52 | $4,549.32 | $4,549.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |