- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,082.70 / $10,900.00 / $14,552.94
| Facility | | $9,082.70 | $10,900.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.25 / $12,015.50 / $17,445.20
| Professional | | $2,225.25 | $12,015.50 | $17,445.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,708.81 / $10,708.81 / $10,708.81
| Professional | | $10,708.81 | $10,708.81 | $10,708.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.52 / $17,445.20 / $24,946.64
| Facility | | $3,813.52 | $17,445.20 | $24,946.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,463.95 / $19,383.00 / $24,992.11
| Professional | | $7,463.95 | $19,383.00 | $24,992.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,537.50 / $13,383.50 / $20,310.84
| Professional | | $11,537.50 | $13,383.50 | $20,310.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.52 / $17,445.20 / $24,946.64
| Facility | | $3,813.52 | $17,445.20 | $24,946.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,028.41 / $13,720.50 / $21,008.29
| Professional | | $3,028.41 | $13,720.50 | $21,008.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,356.04 / $12,850.56 / $19,823.93
| Professional | | $3,356.04 | $12,850.56 | $19,823.93 |