- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,953.53 / $16,953.53 / $16,953.53
| Facility | | $16,953.53 | $16,953.53 | $16,953.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,953.53 / $19,798.34 / $19,798.34
| Professional | | $16,953.53 | $19,798.34 | $19,798.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,787.68 / $25,760.72 / $26,401.54
| Professional | | $21,787.68 | $25,760.72 | $26,401.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,402.38 / $27,676.40 / $34,801.01
| Professional | | $27,402.38 | $27,676.40 | $34,801.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,919.85 / $18,953.70 / $100,282.95
| Facility | | $6,919.85 | $18,953.70 | $100,282.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,283.34 / $15,609.85 / $18,845.18
| Professional | | $9,283.34 | $15,609.85 | $18,845.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,937.71 / $11,625.28 / $18,566.68
| Professional | | $6,937.71 | $11,625.28 | $18,566.68 |