- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,337.76 / $9,531.45 / $27,111.00
| Facility | | $4,337.76 | $9,531.45 | $27,111.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $2,711.10 / $3,137.13
| Professional | | $2,711.10 | $2,711.10 | $3,137.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,371.09 / $7,079.84 / $15,104.70
| Facility | | $6,371.09 | $7,079.84 | $15,104.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.40 / $2,517.44 / $2,517.44
| Professional | | $1,148.40 | $2,517.44 | $2,517.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,993.48 / $14,158.51 / $16,990.27
| Facility | | $6,993.48 | $14,158.51 | $16,990.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,873.00 / $5,621.27 / $12,758.05
| Professional | | $3,873.00 | $5,621.27 | $12,758.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $3,873.00
| Professional | | $1,626.66 | $2,323.80 | $3,873.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |