- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,559.70 / $10,559.70 / $12,671.70
| Facility | | $10,559.70 | $10,559.70 | $12,671.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,987.08 / $8,194.11 / $12,630.80
| Professional | | $7,987.08 | $8,194.11 | $12,630.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,753.97 / $18,753.97 / $22,230.96
| Facility | | $18,753.97 | $18,753.97 | $22,230.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,344.35 / $10,344.35 / $10,855.18
| Professional | | $10,344.35 | $10,344.35 | $10,855.18 |
- 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 / $8,567.87 / $12,512.04
| Professional | | $8,567.87 | $8,567.87 | $12,512.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,184.25 / $15,184.25 / $46,866.19
| Professional | | $15,184.25 | $15,184.25 | $46,866.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,325.77 / $11,109.25 / $15,184.25
| Professional | | $7,325.77 | $11,109.25 | $15,184.25 |