- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,760.63 / $10,760.63 / $10,760.63
| Facility | | $10,760.63 | $10,760.63 | $10,760.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,554.24 / $10,760.63 / $13,257.36
| Professional | | $6,554.24 | $10,760.63 | $13,257.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,544.87 / $8,544.87 / $8,544.87
| Professional | | $8,544.87 | $8,544.87 | $8,544.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,671.78 / $10,671.78 / $11,901.82
| Professional | | $10,671.78 | $10,671.78 | $11,901.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,922.50 / $10,694.63 / $10,694.63
| Facility | | $6,922.50 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.04 / $10,694.63 / $10,694.63
| Professional | | $1,292.04 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,554.24 / $7,584.04 / $11,607.14
| Facility | | $6,554.24 | $7,584.04 | $11,607.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,120.50 / $10,120.50 / $10,120.50
| Professional | | $10,120.50 | $10,120.50 | $10,120.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.67 / $1,491.60 / $14,347.50
| Facility | | $915.67 | $1,491.60 | $14,347.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.67 / $1,491.60 / $14,347.50
| Professional | | $915.67 | $1,491.60 | $14,347.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,819.43 / $5,790.64 / $9,115.60
| Professional | | $4,819.43 | $5,790.64 | $9,115.60 |