- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,682.47 / $5,898.26 / $31,994.50
| Facility | | $5,682.47 | $5,898.26 | $31,994.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,682.47 / $5,754.40 / $7,193.00
| Professional | | $5,682.47 | $5,754.40 | $7,193.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,877.20 / $6,473.70 / $7,559.84
| Facility | | $2,877.20 | $6,473.70 | $7,559.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,445.62 / $2,877.20 / $2,877.20
| Professional | | $2,445.62 | $2,877.20 | $2,877.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,631.60 / $10,070.20 / $11,868.45
| Facility | | $8,631.60 | $10,070.20 | $11,868.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,271.95 / $10,070.20 / $14,386.00
| Professional | | $8,271.95 | $10,070.20 | $14,386.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,675.45 / $5,596.87 / $9,491.16
| Facility | | $4,675.45 | $5,596.87 | $9,491.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.83 / $8,271.95 / $34,670.26
| Professional | | $3,312.83 | $8,271.95 | $34,670.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $4,315.80 / $7,912.30
| Professional | | $3,021.06 | $4,315.80 | $7,912.30 |