- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,054.61 / $21,877.62 / $35,481.34
| Facility | | $19,054.61 | $21,877.62 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,949.84 / $17,782.79
| Professional | | $891.25 | $1,949.84 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $10,964.78
| Facility | | $691.83 | $1,096.48 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,258.93 / $13,489.63
| Facility | | $691.83 | $1,258.93 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $28,840.32 / $28,840.32
| Professional | | $2,454.71 | $28,840.32 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $21,379.62
| Facility | | $14,125.38 | $14,125.38 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,952.62 / $28,840.32 / $28,840.32
| Professional | | $19,952.62 | $28,840.32 | $28,840.32 |