- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,236.10 / $11,236.10 / $11,236.10
| Facility | | $11,236.10 | $11,236.10 | $11,236.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,754.64 / $11,236.10 / $11,927.10
| Professional | | $9,754.64 | $11,236.10 | $11,927.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,485.54 / $10,606.94 / $14,001.16
| Professional | | $8,485.54 | $10,606.94 | $14,001.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.30 / $2,451.79 / $19,983.03
| Facility | | $1,271.30 | $2,451.79 | $19,983.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.72 / $2,574.38 / $19,619.71
| Professional | | $1,543.72 | $2,574.38 | $19,619.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.89 / $11,155.72 / $11,155.72
| Professional | | $1,000.89 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,422.88 / $5,771.04 / $8,129.34
| Professional | | $3,422.88 | $5,771.04 | $8,129.34 |