- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,804.48 / $13,804.48 / $13,804.48
| Facility | | $13,804.48 | $13,804.48 | $13,804.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,682.75 / $13,804.48 / $14,847.39
| Professional | | $13,682.75 | $13,804.48 | $14,847.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,849.79 / $38,005.15 / $49,265.93
| Facility | | $18,849.79 | $38,005.15 | $49,265.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,298.77 / $20,299.78 / $34,799.62
| Professional | | $18,298.77 | $20,299.78 | $34,799.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,524.00 / $16,524.00 / $33,984.00
| Facility | | $16,524.00 | $16,524.00 | $33,984.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,062.52 / $16,524.00 / $138,364.38
| Professional | | $12,062.52 | $16,524.00 | $138,364.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,044.70 / $19,372.84 / $23,407.84
| Professional | | $14,044.70 | $19,372.84 | $23,407.84 |