- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,831.44 / $10,831.44 / $23,356.50
| Facility | | $10,831.44 | $10,831.44 | $23,356.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,676.08 / $10,831.44 / $10,831.44
| Professional | | $6,676.08 | $10,831.44 | $10,831.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,293.61 / $2,824.64 / $14,086.17
| Facility | | $2,293.61 | $2,824.64 | $14,086.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,777.03 / $10,777.03 / $22,406.25
| Professional | | $10,777.03 | $10,777.03 | $22,406.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,444.71 / $10,831.44 / $14,080.87
| Facility | | $4,444.71 | $10,831.44 | $14,080.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,314.66 / $11,314.66 / $11,314.66
| Professional | | $11,314.66 | $11,314.66 | $11,314.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,444.71 / $6,567.65 / $10,775.87
| Professional | | $4,444.71 | $6,567.65 | $10,775.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,163.57 / $71,908.16 / $71,908.16
| Facility | | $14,163.57 | $71,908.16 | $71,908.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67,309.53 / $110,876.63 / $110,876.63
| Professional | | $67,309.53 | $110,876.63 | $110,876.63 |