- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $17,378.01 / $17,378.01
| Facility | | $15,848.93 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $6,025.60
| Professional | | $3,467.37 | $4,073.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $11,220.18
| Professional | | $8,128.31 | $8,128.31 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,606.93 / $15,488.17
| Facility | | $3,467.37 | $6,606.93 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,754.40 / $5,754.40
| Professional | | $5,495.41 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,162.28
| Professional | | $2,187.76 | $2,187.76 | $3,162.28 |