- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,685.10 / $10,294.70 / $29,281.90
| Facility | | $4,685.10 | $10,294.70 | $29,281.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,928.20 / $2,928.20 / $3,388.34
| Professional | | $2,928.20 | $2,928.20 | $3,388.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,881.25 / $7,646.76 / $16,314.21
| Facility | | $6,881.25 | $7,646.76 | $16,314.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $2,719.03 / $2,719.03
| Professional | | $208.00 | $2,719.03 | $2,719.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,543.79 / $13,132.91 / $15,292.10
| Facility | | $9,543.79 | $13,132.91 | $15,292.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,183.13 / $5,677.34 / $12,911.23
| Professional | | $4,183.13 | $5,677.34 | $12,911.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.91 / $2,509.88 / $2,509.88
| Professional | | $1,756.91 | $2,509.88 | $2,509.88 |
- 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 |