- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $11,481.54 / $18,620.87
| Professional | | $9,772.37 | $11,481.54 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Facility | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $24,547.09
| Professional | | $10,715.19 | $10,715.19 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $13,803.84 / $69,183.10
| Facility | | $9,549.93 | $13,803.84 | $69,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $11,220.18 / $29,512.09
| Professional | | $6,606.93 | $11,220.18 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $22,908.68 / $22,908.68
| Facility | | $13,182.57 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,232.93 / $15,135.61
| Professional | | $6,606.93 | $10,232.93 | $15,135.61 |