- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $17,378.01 / $17,378.01
| Facility | | $11,220.18 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,691.53 / $3,162.28
| Professional | | $2,570.40 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,466.84 / $5,011.87
| Facility | | $3,981.07 | $4,466.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $5,623.41
| Professional | | $1,621.81 | $2,344.23 | $5,623.41 |