- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,677.81 / $9,677.81 / $9,677.81
| Facility | | $9,677.81 | $9,677.81 | $9,677.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,677.81 / $11,060.36 / $11,164.89
| Professional | | $9,677.81 | $11,060.36 | $11,164.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $14,513.81
| Facility | | $14,513.81 | $14,513.81 | $14,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $14,513.81 / $14,513.81
| Professional | | $10,595.08 | $14,513.81 | $14,513.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,455.32 / $13,547.09 / $104,478.94
| Facility | | $6,455.32 | $13,547.09 | $104,478.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,666.14 / $13,213.37 / $22,027.14
| Professional | | $6,666.14 | $13,213.37 | $22,027.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,666.14 / $10,487.39 / $15,062.41
| Professional | | $6,666.14 | $10,487.39 | $15,062.41 |