- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,441.66 / $10,441.66 / $10,441.66
| Facility | | $10,441.66 | $10,441.66 | $10,441.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,441.66 / $12,631.57 / $18,386.13
| Professional | | $10,441.66 | $12,631.57 | $18,386.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,200.25 / $16,200.25 / $28,413.71
| Facility | | $16,200.25 | $16,200.25 | $28,413.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,826.18 / $11,826.18 / $24,880.04
| Professional | | $11,826.18 | $11,826.18 | $24,880.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,958.04 / $26,140.61 / $37,221.96
| Professional | | $25,958.04 | $26,140.61 | $37,221.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,747.76 / $28,413.71 / $28,413.71
| Professional | | $27,747.76 | $28,413.71 | $28,413.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,383.10 / $34,568.35 / $41,482.01
| Facility | | $29,383.10 | $34,568.35 | $41,482.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,811.85 / $14,329.83 / $26,085.20
| Professional | | $12,811.85 | $14,329.83 | $26,085.20 |