- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.40 / $7,776.00 / $17,745.59
| Facility | | $2,480.40 | $7,776.00 | $17,745.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $2,810.05
| Professional | | $2,480.40 | $2,480.40 | $2,810.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $536.35 / $910.27 / $15,396.48
| Facility | | $536.35 | $910.27 | $15,396.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.80 / $3,499.20 / $5,793.12
| Professional | | $661.80 | $3,499.20 | $5,793.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,620.28 / $25,010.57 / $44,631.68
| Facility | | $11,620.28 | $25,010.57 | $44,631.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,202.14 / $9,003.71 / $30,623.10
| Professional | | $5,202.14 | $9,003.71 | $30,623.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,443.20 / $10,357.62 / $14,774.40
| Professional | | $5,443.20 | $10,357.62 | $14,774.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,576.96 / $4,665.60 / $13,646.10
| Professional | | $3,576.96 | $4,665.60 | $13,646.10 |