- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $22,908.68 / $22,908.68
| Facility | | $22,908.68 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,620.87 / $22,908.68 / $31,622.78
| Professional | | $18,620.87 | $22,908.68 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,703.96 / $33,884.42 / $33,884.42
| Professional | | $25,703.96 | $33,884.42 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,902.95 / $30,902.95 / $44,668.36
| Professional | | $30,902.95 | $30,902.95 | $44,668.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $27,542.29 / $79,432.82
| Facility | | $19,952.62 | $27,542.29 | $79,432.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $20,417.38 / $38,904.51
| Professional | | $13,182.57 | $20,417.38 | $38,904.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $38,018.94 / $38,018.94
| Facility | | $19,952.62 | $38,018.94 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $20,417.38 / $33,113.11
| Professional | | $13,182.57 | $20,417.38 | $33,113.11 |