- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,091.35 / $10,091.35 / $10,091.35
| Facility | | $10,091.35 | $10,091.35 | $10,091.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,529.76 / $10,091.35 / $16,789.61
| Professional | | $9,529.76 | $10,091.35 | $16,789.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,557.89 / $22,557.89 / $27,146.16
| Professional | | $22,557.89 | $22,557.89 | $27,146.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $16,024.41
| Facility | | $14,513.81 | $14,513.81 | $16,024.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $13,565.29 / $14,513.81
| Professional | | $10,595.08 | $13,565.29 | $14,513.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,038.16 / $15,826.18 / $35,427.07
| Facility | | $10,038.16 | $15,826.18 | $35,427.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,826.18 / $15,826.18 / $15,826.18
| Professional | | $15,826.18 | $15,826.18 | $15,826.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,577.62 / $11,153.51 / $15,065.75
| Professional | | $7,577.62 | $11,153.51 | $15,065.75 |