- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,035.42 / $21,035.42 / $21,035.42
| Facility | | $21,035.42 | $21,035.42 | $21,035.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,035.42 / $23,548.73 / $24,040.48
| Professional | | $21,035.42 | $23,548.73 | $24,040.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35,001.62 / $42,929.43 / $42,929.43
| Professional | | $35,001.62 | $42,929.43 | $42,929.43 |
- 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 / $30,391.12 / $30,391.12
| Professional | | $22,185.52 | $30,391.12 | $30,391.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,628.02 / $29,445.58 / $202,594.16
| Facility | | $12,628.02 | $29,445.58 | $202,594.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,040.44 / $25,848.23 / $48,901.64
| Professional | | $13,040.44 | $25,848.23 | $48,901.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,040.44 / $23,368.42 / $29,465.37
| Professional | | $13,040.44 | $23,368.42 | $29,465.37 |