- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,550.37 / $14,608.97 / $18,303.52
| Facility | | $14,550.37 | $14,608.97 | $18,303.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,695.36 / $14,847.39 / $21,584.17
| Professional | | $12,695.36 | $14,847.39 | $21,584.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,151.96 / $30,136.75 / $56,303.92
| Facility | | $28,151.96 | $30,136.75 | $56,303.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,048.93 / $22,275.00 / $27,106.82
| Professional | | $16,048.93 | $22,275.00 | $27,106.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,524.00 / $16,524.00 / $16,524.00
| Facility | | $16,524.00 | $16,524.00 | $16,524.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,062.52 / $16,524.00 / $17,615.41
| Professional | | $12,062.52 | $16,524.00 | $17,615.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,714.88 / $14,467.62 / $22,503.08
| Professional | | $10,714.88 | $14,467.62 | $22,503.08 |