- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,309.57 / $28,840.32
| Facility | | $6,165.95 | $6,309.57 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,890.45 / $4,786.30
| Professional | | $2,884.03 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $10,471.29 / $21,877.62
| Facility | | $5,495.41 | $10,471.29 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Professional | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,456.54 / $10,471.29
| Professional | | $5,011.87 | $6,456.54 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $10,471.29 / $27,542.29
| Facility | | $151.36 | $10,471.29 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,786.30 / $4,897.79
| Professional | | $4,570.88 | $4,786.30 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,786.30 / $9,772.37
| Facility | | $2,238.72 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $5,011.87
| Professional | | $1,905.46 | $2,884.03 | $5,011.87 |