- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $11,220.18 / $19,952.62
| Professional | | $8,317.64 | $11,220.18 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $18,620.87 / $38,018.94
| Professional | | $15,135.61 | $18,620.87 | $38,018.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $17,378.01 / $25,703.96
| Professional | | $13,803.84 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $12,022.64
| Professional | | $5,011.87 | $5,011.87 | $12,022.64 |