- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $14,791.08 / $16,218.10
| Facility | | $10,232.93 | $14,791.08 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $10,715.19
| Professional | | $5,495.41 | $6,918.31 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,248.07 / $13,489.63
| Professional | | $4,786.30 | $5,248.07 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $16,218.10 / $19,952.62
| Facility | | $10,964.78 | $16,218.10 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Professional | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,232.93 / $39,810.72
| Facility | | $7,413.10 | $10,232.93 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $41,686.94
| Professional | | $1,548.82 | $2,187.76 | $41,686.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $8,511.38 / $10,232.93
| Facility | | $1,548.82 | $8,511.38 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $7,413.10
| Professional | | $1,548.82 | $2,187.76 | $7,413.10 |