- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,039.45 / $10,039.45 / $10,039.45
| Professional | | $10,039.45 | $10,039.45 | $10,039.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,418.85 / $11,247.62 / $11,839.60
| Professional | | $10,418.85 | $11,247.62 | $11,839.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $17,568.75
| Professional | | $7,447.14 | $7,447.14 | $17,568.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,698.18 / $8,082.54 / $11,193.41
| Facility | | $4,698.18 | $8,082.54 | $11,193.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.77 / $4,032.28 / $6,326.00
| Professional | | $2,640.77 | $4,032.28 | $6,326.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.34 / $1,598.35 / $3,152.19
| Facility | | $1,381.34 | $1,598.35 | $3,152.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.85 / $1,744.94 / $3,152.19
| Professional | | $1,557.85 | $1,744.94 | $3,152.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,839.65 / $4,032.28 / $6,040.53
| Professional | | $2,839.65 | $4,032.28 | $6,040.53 |