- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,471.29
| Facility | | $10,232.93 | $10,232.93 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,309.57 / $10,471.29
| Professional | | $4,786.30 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $15,488.17 / $16,982.44
| Professional | | $11,748.98 | $15,488.17 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $18,197.01
| Professional | | $14,454.40 | $14,454.40 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $10,471.29 / $54,954.09
| Facility | | $5,128.61 | $10,471.29 | $54,954.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,079.46 / $12,589.25
| Professional | | $4,786.30 | $7,079.46 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $17,378.01 / $17,378.01
| Facility | | $6,918.31 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,943.28 / $14,454.40
| Professional | | $4,073.80 | $7,943.28 | $14,454.40 |