- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,308.01 / $8,452.23 / $25,813.48
| Facility | | $6,308.01 | $8,452.23 | $25,813.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,452.23 / $10,246.95 / $14,522.21
| Professional | | $8,452.23 | $10,246.95 | $14,522.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $23,000.09
| Facility | | $13,034.23 | $13,034.23 | $23,000.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $11,079.10 / $20,139.68
| Professional | | $11,079.10 | $11,079.10 | $20,139.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,012.31 / $21,160.08 / $30,130.12
| Professional | | $21,012.31 | $21,160.08 | $30,130.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,640.58 / $10,640.58 / $15,299.33
| Professional | | $10,640.58 | $10,640.58 | $15,299.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,406.57 / $11,988.04 / $23,000.09
| Professional | | $10,406.57 | $11,988.04 | $23,000.09 |