- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,547.09 / $38,018.94 / $38,018.94
| Facility | | $24,547.09 | $38,018.94 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,888.44 / $6,918.31
| Professional | | $5,495.41 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $9,772.37 / $10,715.19
| Facility | | $8,709.64 | $9,772.37 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $25,703.96 / $25,703.96
| Facility | | $25,703.96 | $25,703.96 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $8,511.38
| Professional | | $1,819.70 | $2,187.76 | $8,511.38 |