- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,917.20 / $9,460.79 / $19,276.96
| Facility | | $4,917.20 | $9,460.79 | $19,276.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.10 / $2,954.31 / $3,506.40
| Professional | | $1,466.10 | $2,954.31 | $3,506.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,535.24 / $21,072.03 / $36,980.03
| Facility | | $14,535.24 | $21,072.03 | $36,980.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,963.70 / $3,704.62 / $6,204.07
| Professional | | $2,963.70 | $3,704.62 | $6,204.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,730.00 / $7,441.00 / $9,719.69
| Facility | | $2,730.00 | $7,441.00 | $9,719.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,232.93 / $17,232.93 / $17,232.93
| Professional | | $17,232.93 | $17,232.93 | $17,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,178.00 / $7,441.00 / $8,816.00
| Facility | | $6,178.00 | $7,441.00 | $8,816.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.73 / $68.73 / $84.10
| Professional | | $68.73 | $68.73 | $84.10 |