- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32,882.44 / $32,882.44 / $32,882.44
| Facility | | $32,882.44 | $32,882.44 | $32,882.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,933.26 / $28,804.37 / $32,882.44
| Professional | | $26,933.26 | $28,804.37 | $32,882.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36,916.04 / $43,647.79 / $44,733.56
| Professional | | $36,916.04 | $43,647.79 | $44,733.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44,937.75 / $45,387.13 / $57,070.94
| Professional | | $44,937.75 | $45,387.13 | $57,070.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,933.26 / $32,882.44 / $182,487.33
| Facility | | $26,933.26 | $32,882.44 | $182,487.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,970.96 / $23,186.58 / $35,090.75
| Professional | | $16,970.96 | $23,186.58 | $35,090.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,262.05 / $19,874.21 / $34,779.87
| Professional | | $11,262.05 | $19,874.21 | $34,779.87 |