- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $15,488.17 / $20,892.96
| Facility | | $8,511.38 | $15,488.17 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,918.31 / $6,918.31
| Professional | | $6,309.57 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $11,481.54 / $11,481.54
| Facility | | $10,964.78 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Professional | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,754.40
| Facility | | $5,495.41 | $5,495.41 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $8,511.38
| Facility | | $3,311.31 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $8,128.31
| Professional | | $1,548.82 | $2,187.76 | $8,128.31 |