- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $18,620.87
| Facility | | $16,595.87 | $16,595.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $12,022.64 / $18,620.87
| Professional | | $9,549.93 | $12,022.64 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,620.87 / $25,118.86 / $27,542.29
| Professional | | $18,620.87 | $25,118.86 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,302.68 / $26,302.68 / $32,359.37
| Professional | | $26,302.68 | $26,302.68 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $18,620.87 / $104,712.85
| Facility | | $9,772.37 | $18,620.87 | $104,712.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $11,220.18 / $22,908.68
| Professional | | $9,120.11 | $11,220.18 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $32,359.37 / $32,359.37
| Facility | | $13,182.57 | $32,359.37 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $15,135.61 / $23,988.33
| Professional | | $7,762.47 | $15,135.61 | $23,988.33 |