- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,190.57 / $12,940.76 / $18,379.64
| Facility | | $12,190.57 | $12,940.76 | $18,379.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,875.32 / $12,940.76 / $18,754.73
| Professional | | $9,875.32 | $12,940.76 | $18,754.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,632.45 / $33,539.08 / $47,143.76
| Facility | | $19,632.45 | $33,539.08 | $47,143.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,388.62 / $16,014.61 / $16,014.61
| Professional | | $13,388.62 | $16,014.61 | $16,014.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $14,513.81
| Facility | | $14,513.81 | $14,513.81 | $14,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $14,513.81 / $14,513.81
| Professional | | $10,595.08 | $14,513.81 | $14,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,666.14 / $11,696.06 / $15,942.11
| Professional | | $6,666.14 | $11,696.06 | $15,942.11 |