- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $16,595.87 / $23,442.29
| Facility | | $15,488.17 | $16,595.87 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $16,218.10 / $19,498.45
| Professional | | $15,488.17 | $16,218.10 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $19,054.61 / $38,018.94
| Facility | | $5,011.87 | $19,054.61 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $16,218.10 / $19,498.45
| Professional | | $5,370.32 | $16,218.10 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $16,595.87 / $16,595.87
| Facility | | $13,803.84 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $16,595.87 / $16,595.87
| Professional | | $4,466.84 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,265.80 / $8,709.64
| Facility | | $3,162.28 | $4,265.80 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $19,498.45
| Professional | | $16,218.10 | $16,218.10 | $19,498.45 |