- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,606.93 / $20,417.38
| Facility | | $5,011.87 | $6,606.93 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,786.30 / $5,754.40
| Professional | | $4,265.80 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,466.84 / $7,762.47
| Facility | | $1,479.11 | $4,466.84 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,248.07 / $6,165.95
| Professional | | $4,786.30 | $5,248.07 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,786.30 / $4,786.30
| Facility | | $4,466.84 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,495.41 / $13,182.57
| Facility | | $2,951.21 | $5,495.41 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,786.30 / $10,232.93
| Facility | | $4,677.35 | $4,786.30 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,786.30 / $5,248.07
| Professional | | $4,677.35 | $4,786.30 | $5,248.07 |