- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,957.91 / $21,957.91 / $21,957.91
| Facility | | $21,957.91 | $21,957.91 | $21,957.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,714.66 / $21,464.72 / $22,358.33
| Professional | | $18,714.66 | $21,464.72 | $22,358.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35,012.91 / $45,177.95 / $51,688.09
| Facility | | $35,012.91 | $45,177.95 | $51,688.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,953.47 / $23,953.47 / $25,020.52
| Professional | | $23,953.47 | $23,953.47 | $25,020.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,391.12 / $30,391.12 / $30,391.12
| Facility | | $30,391.12 | $30,391.12 | $30,391.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,185.52 / $22,185.52 / $30,391.12
| Professional | | $22,185.52 | $22,185.52 | $30,391.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,365.67 / $29,365.67 / $29,365.67
| Facility | | $29,365.67 | $29,365.67 | $29,365.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,044.88 / $29,365.67 / $39,694.29
| Professional | | $28,044.88 | $29,365.67 | $39,694.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,910.33 / $24,910.33 / $24,910.33
| Professional | | $24,910.33 | $24,910.33 | $24,910.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,200.41 / $22,538.78 / $30,142.37
| Professional | | $17,200.41 | $22,538.78 | $30,142.37 |