- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,670.52 / $7,670.52 / $19,694.58
| Facility | | $7,670.52 | $7,670.52 | $19,694.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,670.52 / $10,654.00 / $19,694.58
| Professional | | $7,670.52 | $10,654.00 | $19,694.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,528.24 / $12,562.19 / $27,812.64
| Professional | | $12,528.24 | $12,562.19 | $27,812.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $13,034.23
| Facility | | $13,034.23 | $13,034.23 | $13,034.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $11,079.10 / $13,425.26
| Professional | | $11,079.10 | $11,079.10 | $13,425.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,165.71 / $18,940.43 / $30,778.22
| Professional | | $13,165.71 | $18,940.43 | $30,778.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,795.68 / $14,929.55 / $21,308.00
| Professional | | $9,795.68 | $14,929.55 | $21,308.00 |