- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,917.13 / $16,917.13 / $16,917.13
| Facility | | $16,917.13 | $16,917.13 | $16,917.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,568.13 / $18,002.73 / $28,804.37
| Professional | | $15,568.13 | $18,002.73 | $28,804.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39,235.19 / $39,235.19 / $39,235.19
| Facility | | $39,235.19 | $39,235.19 | $39,235.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,019.05 / $31,019.05 / $44,937.75
| Professional | | $31,019.05 | $31,019.05 | $44,937.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36,096.37 / $43,158.71 / $51,398.10
| Professional | | $36,096.37 | $43,158.71 | $51,398.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,315.61 / $39,235.19 / $39,235.19
| Professional | | $38,315.61 | $39,235.19 | $39,235.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,552.08 / $20,613.43 / $39,235.19
| Professional | | $18,552.08 | $20,613.43 | $39,235.19 |