- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $17,378.01 / $17,378.01
| Facility | | $11,220.18 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $9,549.93
| Professional | | $2,570.40 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,466.84 / $5,011.87
| Facility | | $3,467.37 | $4,466.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $4,265.80
| Professional | | $2,187.76 | $2,884.03 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,344.23
| Professional | | $2,187.76 | $2,187.76 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $5,623.41
| Professional | | $1,621.81 | $2,344.23 | $5,623.41 |