- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,963.41 / $12,963.41 / $12,963.41
| Facility | | $12,963.41 | $12,963.41 | $12,963.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,478.66 / $9,025.16 / $14,440.25
| Professional | | $5,478.66 | $9,025.16 | $14,440.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,045.03 / $21,045.03 / $21,045.03
| Professional | | $21,045.03 | $21,045.03 | $21,045.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $11,736.82
| Facility | | $11,736.82 | $11,736.82 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $11,736.82 / $26,292.19
| Professional | | $8,567.87 | $11,736.82 | $26,292.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,478.66 / $13,894.13 / $87,176.00
| Facility | | $5,478.66 | $13,894.13 | $87,176.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,657.59 / $9,871.27 / $22,025.27
| Professional | | $5,657.59 | $9,871.27 | $22,025.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,733.93 / $8,600.89 / $13,077.26
| Professional | | $5,733.93 | $8,600.89 | $13,077.26 |