- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,175.40 / $10,175.40 / $10,175.40
| Facility | | $10,175.40 | $10,175.40 | $10,175.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,833.77 / $10,175.36 / $10,801.13
| Professional | | $8,833.77 | $10,175.36 | $10,801.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,675.22 / $8,071.90 / $10,654.90
| Professional | | $7,675.22 | $8,071.90 | $10,654.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.28 / $2,138.10 / $14,961.90
| Facility | | $1,151.28 | $2,138.10 | $14,961.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.05 / $1,973.63 / $17,346.31
| Professional | | $1,069.05 | $1,973.63 | $17,346.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.41 / $10,102.62 / $10,102.62
| Professional | | $906.41 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,099.73 / $5,241.80 / $7,361.86
| Professional | | $3,099.73 | $5,241.80 | $7,361.86 |