- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $9,772.37 / $15,488.17
| Facility | | $3,630.78 | $9,772.37 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,265.80 / $5,248.07
| Professional | | $3,311.31 | $4,265.80 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $6,025.60 / $7,079.46
| Facility | | $131.83 | $6,025.60 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $5,495.41 / $5,495.41
| Professional | | $66.07 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,022.64 / $16,595.87
| Facility | | $8,511.38 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,902.95 / $30,902.95 / $30,902.95
| Professional | | $30,902.95 | $30,902.95 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,025.60 / $7,585.78
| Professional | | $4,897.79 | $6,025.60 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,413.10 / $11,748.98
| Professional | | $5,495.41 | $7,413.10 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,495.41
| Facility | | $4,897.79 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $7,585.78
| Professional | | $2,290.87 | $3,311.31 | $7,585.78 |