- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,117.68 / $10,286.46 / $27,500.00
| Facility | | $5,117.68 | $10,286.46 | $27,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.34 / $5,117.68 / $9,304.87
| Professional | | $4,466.34 | $5,117.68 | $9,304.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,775.93 / $10,264.73 / $45,125.69
| Facility | | $9,775.93 | $10,264.73 | $45,125.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,018.60 / $6,763.84 / $8,041.07
| Professional | | $5,018.60 | $6,763.84 | $8,041.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,957.05 / $7,957.05 / $7,957.05
| Facility | | $7,957.05 | $7,957.05 | $7,957.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,763.49 / $6,763.49 / $8,195.76
| Professional | | $6,763.49 | $6,763.49 | $8,195.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.34 / $7,878.61 / $43,045.38
| Facility | | $4,466.34 | $7,878.61 | $43,045.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,722.42 / $5,225.60 / $8,963.95
| Professional | | $3,722.42 | $5,225.60 | $8,963.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,938.27 / $11,938.27 / $14,325.92
| Facility | | $11,938.27 | $11,938.27 | $14,325.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,722.42 / $4,914.17 / $6,922.83
| Professional | | $3,722.42 | $4,914.17 | $6,922.83 |