- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.30 / $24,754.59 / $48,800.52
| Facility | | $2,206.30 | $24,754.59 | $48,800.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,632.14 / $9,955.01 / $10,915.67
| Professional | | $9,632.14 | $9,955.01 | $10,915.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $13,034.23
| Facility | | $13,034.23 | $13,034.23 | $13,034.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $11,079.10 / $13,034.23
| Professional | | $11,079.10 | $11,079.10 | $13,034.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116,308.92 / $116,308.92 / $116,308.92
| Facility | | $116,308.92 | $116,308.92 | $116,308.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,542.68 / $12,510.66 / $17,588.72
| Professional | | $10,542.68 | $12,510.66 | $17,588.72 |