- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,493.04 / $24,493.04 / $24,493.04
| Facility | | $24,493.04 | $24,493.04 | $24,493.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,439.70 / $24,493.04 / $24,493.04
| Professional | | $12,439.70 | $24,493.04 | $24,493.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,852.92 / $21,852.92 / $21,852.92
| Professional | | $21,852.92 | $21,852.92 | $21,852.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,995.48 / $19,995.48 / $19,995.48
| Professional | | $19,995.48 | $19,995.48 | $19,995.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,200.25 / $16,200.25 / $28,980.18
| Facility | | $16,200.25 | $16,200.25 | $28,980.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,826.18 / $16,200.25 / $27,733.26
| Professional | | $11,826.18 | $16,200.25 | $27,733.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,383.10 / $29,383.10 / $34,568.35
| Facility | | $29,383.10 | $29,383.10 | $34,568.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,622.87 / $14,536.25 / $20,011.57
| Professional | | $8,622.87 | $14,536.25 | $20,011.57 |