- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $30,199.52 / $47,863.01
| Facility | | $16,595.87 | $30,199.52 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,630.78 / $12,882.50
| Professional | | $3,162.28 | $3,630.78 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $17,378.01
| Facility | | $3,890.45 | $3,890.45 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $12,589.25
| Professional | | $3,890.45 | $3,890.45 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $14,454.40 / $15,488.17
| Facility | | $3,890.45 | $14,454.40 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Professional | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $10,715.19 / $18,620.87
| Facility | | $3,090.30 | $10,715.19 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $7,762.47 / $11,748.98
| Professional | | $2,344.23 | $7,762.47 | $11,748.98 |