- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $11,220.18 / $19,952.62
| Professional | | $9,332.54 | $11,220.18 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $23,442.29
| Facility | | $22,387.21 | $22,387.21 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $15,848.93
| Professional | | $12,589.25 | $12,589.25 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $14,454.40 / $17,378.01
| Facility | | $10,715.19 | $14,454.40 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $15,488.17
| Professional | | $10,715.19 | $10,715.19 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,302.69 / $22,387.21 / $38,904.51
| Professional | | $12,302.69 | $22,387.21 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,952.62 / $22,387.21 / $22,908.68
| Professional | | $19,952.62 | $22,387.21 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $13,182.57 / $15,135.61
| Facility | | $7,585.78 | $13,182.57 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $14,454.40 / $20,417.38
| Professional | | $9,332.54 | $14,454.40 | $20,417.38 |