- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,821.91 / $20,514.68 / $63,132.36
| Facility | | $15,821.91 | $20,514.68 | $63,132.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,821.91 / $15,821.91 / $15,821.91
| Professional | | $15,821.91 | $15,821.91 | $15,821.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,434.82 / $16,633.74 / $18,728.48
| Facility | | $10,434.82 | $16,633.74 | $18,728.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,985.01 / $9,970.00 / $9,970.00
| Professional | | $4,985.01 | $9,970.00 | $9,970.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |