- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,606.93 / $30,199.52
| Facility | | $6,456.54 | $6,606.93 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,265.80 / $5,011.87
| Professional | | $3,311.31 | $4,265.80 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $10,964.78 / $11,748.98
| Facility | | $4,897.79 | $10,964.78 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,606.93 / $10,964.78
| Professional | | $5,248.07 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $30,199.52
| Facility | | $134.90 | $11,481.54 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $5,011.87
| Professional | | $3,981.07 | $3,981.07 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,011.87 / $10,232.93
| Facility | | $2,344.23 | $5,011.87 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $5,248.07
| Professional | | $1,995.26 | $3,019.95 | $5,248.07 |