- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,481.54 / $19,952.62
| Professional | | $9,549.93 | $11,481.54 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $22,387.21
| Facility | | $22,387.21 | $22,387.21 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $22,387.21
| Professional | | $22,387.21 | $22,387.21 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $25,118.86
| Facility | | $14,454.40 | $14,454.40 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $19,952.62
| Professional | | $10,715.19 | $10,715.19 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $13,182.57 / $18,197.01
| Facility | | $7,585.78 | $13,182.57 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $10,000.00 / $15,488.17
| Professional | | $9,120.11 | $10,000.00 | $15,488.17 |