- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $32,359.37 / $66,069.34
| Facility | | $15,848.93 | $32,359.37 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $15,848.93 / $15,848.93
| Professional | | $14,125.38 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,000.00 / $10,000.00
| Professional | | $6,760.83 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Professional | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |