- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $11,481.54 / $17,378.01
| Professional | | $7,585.78 | $11,481.54 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,220.18 / $11,220.18
| Professional | | $9,549.93 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $6,760.83
| Facility | | $891.25 | $1,023.29 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,495.41 / $10,000.00
| Professional | | $3,981.07 | $5,495.41 | $10,000.00 |