- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $38,018.94
| Facility | | $13,803.84 | $13,803.84 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $3,801.89 / $4,466.84
| Professional | | $588.84 | $3,801.89 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $10,471.29 / $31,622.78
| Facility | | $9,549.93 | $10,471.29 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $3,548.13 / $5,128.61
| Professional | | $66.07 | $3,548.13 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $23,988.33
| Facility | | $8,912.51 | $17,378.01 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $10,471.29
| Professional | | $5,495.41 | $5,495.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $5,495.41
| Professional | | $3,311.31 | $3,311.31 | $5,495.41 |