- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,855.56 / $15,855.56 / $15,855.56
| Facility | | $15,855.56 | $15,855.56 | $15,855.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,855.56 / $18,776.22 / $27,659.65
| Professional | | $15,855.56 | $18,776.22 | $27,659.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,228.07 / $30,391.12 / $43,145.97
| Facility | | $24,228.07 | $30,391.12 | $43,145.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,185.52 / $22,185.52 / $37,780.12
| Professional | | $22,185.52 | $22,185.52 | $37,780.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39,417.04 / $39,694.29 / $56,521.22
| Professional | | $39,417.04 | $39,694.29 | $56,521.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41,067.00 / $43,145.97 / $43,145.97
| Professional | | $41,067.00 | $43,145.97 | $43,145.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,454.66 / $22,697.12 / $43,145.97
| Professional | | $19,454.66 | $22,697.12 | $43,145.97 |