- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,738.05 / $10,738.05 / $10,738.05
| Facility | | $10,738.05 | $10,738.05 | $10,738.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,643.36 / $10,738.05 / $11,549.30
| Professional | | $10,643.36 | $10,738.05 | $11,549.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,662.63 / $29,562.98 / $38,322.37
| Facility | | $14,662.63 | $29,562.98 | $38,322.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,234.03 / $15,790.52 / $27,069.47
| Professional | | $14,234.03 | $15,790.52 | $27,069.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $26,435.03
| Facility | | $14,513.81 | $14,513.81 | $26,435.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $14,513.81 / $107,604.38
| Professional | | $10,595.08 | $14,513.81 | $107,604.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,924.91 / $13,968.01 / $18,208.18
| Professional | | $10,924.91 | $13,968.01 | $18,208.18 |