- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,022.64 / $16,595.87
| Facility | | $7,413.10 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $12,022.64
| Professional | | $2,344.23 | $3,311.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Professional | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $16,595.87
| Facility | | $2,884.03 | $3,801.89 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $8,128.31 / $16,982.44
| Professional | | $6,309.57 | $8,128.31 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $15,488.17
| Professional | | $10,715.19 | $10,715.19 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $12,022.64 / $16,982.44
| Facility | | $3,715.35 | $12,022.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $2,454.71 / $8,317.64
| Professional | | $60.26 | $2,454.71 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,760.83 / $15,488.17
| Professional | | $6,606.93 | $6,760.83 | $15,488.17 |