- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,249.07 / $44,609.38 / $48,564.77
| Facility | | $11,249.07 | $44,609.38 | $48,564.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,249.07 / $11,474.05 / $12,598.95
| Professional | | $11,249.07 | $11,474.05 | $12,598.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,562.19 / $12,562.19 / $24,245.03
| Facility | | $12,562.19 | $12,562.19 | $24,245.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,842.26 / $12,562.19 / $17,335.82
| Professional | | $11,842.26 | $12,562.19 | $17,335.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,727.80 / $26,000.78 / $34,467.44
| Facility | | $17,727.80 | $26,000.78 | $34,467.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,091.50 / $26,000.78 / $31,910.04
| Professional | | $20,091.50 | $26,000.78 | $31,910.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $23,637.07
| Facility | | $13,034.23 | $13,034.23 | $23,637.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $13,034.23 / $24,247.07
| Professional | | $11,079.10 | $13,034.23 | $24,247.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,937.71 / $11,792.27 / $16,036.20
| Professional | | $6,937.71 | $11,792.27 | $16,036.20 |