- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,718.30 / $29,160.00 / $63,597.85
| Facility | | $6,718.30 | $29,160.00 | $63,597.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,718.30 / $7,670.52 / $68,309.70
| Professional | | $6,718.30 | $7,670.52 | $68,309.70 |
- 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 / $13,034.23 / $27,402.38
| Professional | | $11,079.10 | $13,034.23 | $27,402.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $17,011.29 / $22,114.67
| Professional | | $60.00 | $17,011.29 | $22,114.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,958.17 / $16,311.63 / $24,467.45
| Professional | | $12,958.17 | $16,311.63 | $24,467.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,396.20 / $10,406.57 / $17,476.75
| Professional | | $9,396.20 | $10,406.57 | $17,476.75 |