- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,577.40 / $15,577.40 / $15,577.40
| Facility | | $15,577.40 | $15,577.40 | $15,577.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,554.24 / $11,434.47 / $15,577.40
| Professional | | $6,554.24 | $11,434.47 | $15,577.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,629.80 / $13,629.80 / $13,629.80
| Professional | | $13,629.80 | $13,629.80 | $13,629.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,694.63 / $10,694.63 / $10,694.63
| Facility | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.51 / $10,694.63 / $25,228.13
| Professional | | $1,230.51 | $10,694.63 | $25,228.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,554.24 / $11,434.47 / $15,015.73
| Facility | | $6,554.24 | $11,434.47 | $15,015.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,281.36 / $5,464.43 / $8,203.40
| Professional | | $3,281.36 | $5,464.43 | $8,203.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,333.12 / $5,190.14 / $7,806.33
| Professional | | $3,333.12 | $5,190.14 | $7,806.33 |