- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,531.66 / $13,531.66 / $13,531.66
| Facility | | $13,531.66 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,748.77 / $13,531.66 / $13,531.66
| Professional | | $7,748.77 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,789.42 / $13,045.21 / $75,283.64
| Facility | | $12,789.42 | $13,045.21 | $75,283.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,231.54 / $12,789.42 / $13,045.21
| Professional | | $10,231.54 | $12,789.42 | $13,045.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,619.91 / $11,619.91 / $11,619.91
| Facility | | $11,619.91 | $11,619.91 | $11,619.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,876.92 / $9,876.92 / $9,876.92
| Professional | | $9,876.92 | $9,876.92 | $9,876.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,156.60 / $13,531.66 / $16,247.00
| Facility | | $8,156.60 | $13,531.66 | $16,247.00 |