- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,704.20 / $12,462.70 / $33,735.40
| Facility | | $7,704.20 | $12,462.70 | $33,735.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,341.25 / $7,017.65 / $7,186.75
| Professional | | $6,341.25 | $7,017.65 | $7,186.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,387.77 / $16,663.43 / $26,397.21
| Facility | | $4,387.77 | $16,663.43 | $26,397.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,547.75 / $8,069.46 / $39,086.43
| Professional | | $5,547.75 | $8,069.46 | $39,086.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,647.85 / $13,739.38 / $24,730.88
| Facility | | $5,647.85 | $13,739.38 | $24,730.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,664.85 / $8,455.00 / $15,436.64
| Facility | | $5,664.85 | $8,455.00 | $15,436.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $1,543.50 / $42,105.90
| Professional | | $1,543.50 | $1,543.50 | $42,105.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $1,543.50 / $3,551.10
| Professional | | $1,543.50 | $1,543.50 | $3,551.10 |