- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,225.27 / $7,225.27 / $18,551.36
| Facility | | $7,225.27 | $7,225.27 | $18,551.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,225.27 / $10,035.56 / $18,551.36
| Professional | | $7,225.27 | $10,035.56 | $18,551.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,301.24 / $22,301.24 / $22,301.24
| Facility | | $22,301.24 | $22,301.24 | $22,301.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,519.84 / $11,663.83 / $25,573.88
| Professional | | $11,519.84 | $11,663.83 | $25,573.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,847.37 / $13,847.37 / $16,417.65
| Facility | | $13,847.37 | $13,847.37 | $16,417.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,108.58 / $13,549.79 / $14,262.79
| Professional | | $10,108.58 | $13,549.79 | $14,262.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,401.47 / $17,840.99 / $28,991.61
| Professional | | $12,401.47 | $17,840.99 | $28,991.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,847.23 / $11,920.85 / $14,901.06
| Professional | | $8,847.23 | $11,920.85 | $14,901.06 |