- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $21,379.62 / $58,884.37
| Facility | | $21,379.62 | $21,379.62 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,309.57 / $6,918.31
| Professional | | $4,570.88 | $6,309.57 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $16,218.10 / $48,977.88
| Facility | | $14,454.40 | $16,218.10 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $5,495.41 / $7,943.28
| Professional | | $208.93 | $5,495.41 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $26,302.68 / $37,153.52
| Facility | | $13,803.84 | $26,302.68 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $16,218.10
| Professional | | $8,511.38 | $8,511.38 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $8,511.38
| Professional | | $2,187.76 | $2,187.76 | $8,511.38 |