- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,025.60 / $10,715.19
| Facility | | $2,951.21 | $6,025.60 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,244.36 / $11,220.18
| Professional | | $5,128.61 | $7,244.36 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $25,703.96 / $56,234.13
| Facility | | $15,848.93 | $25,703.96 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,709.64 / $13,489.63
| Professional | | $6,606.93 | $8,709.64 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Professional | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $8,709.64
| Professional | | $933.25 | $933.25 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $19,054.61 / $32,359.37
| Facility | | $13,489.63 | $19,054.61 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,589.25 / $16,218.10 / $26,302.68
| Professional | | $12,589.25 | $16,218.10 | $26,302.68 |