- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,413.10 / $11,748.98
| Professional | | $5,495.41 | $7,413.10 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $18,197.01 / $19,952.62
| Professional | | $13,489.63 | $18,197.01 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $20,417.38
| Professional | | $16,218.10 | $16,218.10 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $11,748.98 / $63,095.73
| Facility | | $5,888.44 | $11,748.98 | $63,095.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,128.31 / $14,454.40
| Professional | | $5,495.41 | $8,128.31 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $19,952.62 / $19,952.62
| Facility | | $8,128.31 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $9,120.11 / $16,218.10
| Professional | | $4,786.30 | $9,120.11 | $16,218.10 |