- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,634.62 / $8,634.62 / $18,143.50
| Facility | | $8,634.62 | $8,634.62 | $18,143.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,571.70 / $8,807.32 / $9,459.39
| Professional | | $8,571.70 | $8,807.32 | $9,459.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,333.37 / $16,238.43 / $18,143.50
| Facility | | $14,333.37 | $16,238.43 | $18,143.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,089.95 / $10,344.35 / $14,275.20
| Professional | | $9,089.95 | $10,344.35 | $14,275.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,607.63 / $19,957.84 / $25,977.81
| Facility | | $13,607.63 | $19,957.84 | $25,977.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,421.98 / $19,957.84 / $24,493.73
| Professional | | $15,421.98 | $19,957.84 | $24,493.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $18,143.50
| Facility | | $11,736.82 | $11,736.82 | $18,143.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $11,736.82 / $18,611.72
| Professional | | $8,567.87 | $11,736.82 | $18,611.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,657.59 / $9,051.59 / $12,985.66
| Professional | | $5,657.59 | $9,051.59 | $12,985.66 |