- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,005.46 / $15,005.46 / $15,005.46
| Facility | | $15,005.46 | $15,005.46 | $15,005.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,005.46 / $15,005.46 / $15,005.46
| Professional | | $15,005.46 | $15,005.46 | $15,005.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,423.63 / $15,776.54 / $19,244.50
| Professional | | $15,423.63 | $15,776.54 | $19,244.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,062.52 / $12,062.52 / $12,062.52
| Professional | | $12,062.52 | $12,062.52 | $12,062.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,298.77 / $18,298.77 / $55,883.29
| Professional | | $18,298.77 | $18,298.77 | $55,883.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,363.14 / $14,044.70 / $19,896.66
| Professional | | $9,363.14 | $14,044.70 | $19,896.66 |