- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $25,118.86 / $25,118.86
| Facility | | $11,481.54 | $25,118.86 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,754.40 / $8,709.64
| Professional | | $2,691.53 | $5,754.40 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $16,218.10
| Professional | | $11,748.98 | $11,748.98 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $9,120.11 / $22,387.21
| Facility | | $2,691.53 | $9,120.11 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,317.64 / $10,964.78
| Professional | | $7,943.28 | $8,317.64 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,570.88
| Professional | | $3,162.28 | $3,162.28 | $4,570.88 |