- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,168.59 / $10,293.40 / $16,863.59
| Facility | | $5,168.59 | $10,293.40 | $16,863.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,832.64 / $3,832.64 / $4,380.16
| Professional | | $3,832.64 | $3,832.64 | $4,380.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.27 / $76.79 / $7,106.80
| Professional | | $56.27 | $76.79 | $7,106.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.20 / $16,014.96 / $128,119.70
| Facility | | $5,475.20 | $16,014.96 | $128,119.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,723.72 / $13,140.48 / $128,783.67
| Professional | | $5,723.72 | $13,140.48 | $128,783.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,886.34 / $5,637.27 / $31,703.21
| Facility | | $4,886.34 | $5,637.27 | $31,703.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,817.52 / $30,817.52 / $30,817.52
| Professional | | $30,817.52 | $30,817.52 | $30,817.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,886.34 / $5,637.27 / $31,703.21
| Facility | | $4,886.34 | $5,637.27 | $31,703.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $7,231.10
| Professional | | $2,299.58 | $3,285.12 | $7,231.10 |