- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $18,197.01
| Facility | | $11,748.98 | $11,748.98 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $11,481.54 / $17,782.79
| Professional | | $9,120.11 | $11,481.54 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Professional | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $12,882.50
| Professional | | $9,332.54 | $9,332.54 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $16,595.87 / $25,703.96
| Facility | | $12,302.69 | $16,595.87 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,232.93 / $15,135.61
| Professional | | $6,309.57 | $10,232.93 | $15,135.61 |