- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $52,480.75
| Facility | | $19,054.61 | $19,054.61 | $52,480.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $5,888.44
| Professional | | $2,691.53 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $14,454.40 / $43,651.58
| Facility | | $13,182.57 | $14,454.40 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $4,897.79 / $7,079.46
| Professional | | $851.14 | $4,897.79 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $23,988.33 / $33,113.11
| Facility | | $12,302.69 | $23,988.33 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $14,454.40
| Professional | | $7,585.78 | $7,585.78 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $7,943.28
| Professional | | $4,570.88 | $4,570.88 | $7,943.28 |