- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,391.46 / $12,669.90 / $20,757.09
| Facility | | $5,391.46 | $12,669.90 | $20,757.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,717.53 / $5,391.46 / $5,391.46
| Professional | | $4,717.53 | $5,391.46 | $5,391.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.88 / $512.25 / $8,747.65
| Professional | | $426.88 | $512.25 | $8,747.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,739.33 / $19,712.54 / $157,700.29
| Facility | | $6,739.33 | $19,712.54 | $157,700.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,045.18 / $16,174.39 / $158,516.54
| Professional | | $7,045.18 | $16,174.39 | $158,516.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,665.98 / $14,193.01 / $45,435.61
| Facility | | $7,665.98 | $14,193.01 | $45,435.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,665.98 / $14,193.01 / $45,435.61
| Facility | | $7,665.98 | $14,193.01 | $45,435.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $4,043.60 / $9,819.20
| Professional | | $2,830.52 | $4,043.60 | $9,819.20 |