- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $46,773.51
| Facility | | $16,982.44 | $16,982.44 | $46,773.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $5,495.41
| Professional | | $3,630.78 | $5,011.87 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $12,882.50 / $38,904.51
| Facility | | $11,748.98 | $12,882.50 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $4,365.16 / $6,309.57
| Professional | | $426.58 | $4,365.16 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $21,379.62 / $29,512.09
| Facility | | $10,964.78 | $21,379.62 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $12,882.50
| Professional | | $6,760.83 | $6,760.83 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $6,760.83
| Professional | | $4,073.80 | $4,073.80 | $6,760.83 |