- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,999.98 / $8,999.98 / $10,800.00
| Facility | | $8,999.98 | $8,999.98 | $10,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,901.87 / $6,983.78 / $8,999.98
| Professional | | $6,901.87 | $6,983.78 | $8,999.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,983.88 / $15,983.88 / $18,947.29
| Facility | | $15,983.88 | $15,983.88 | $18,947.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,832.85 / $8,832.85 / $9,226.33
| Professional | | $8,832.85 | $8,832.85 | $9,226.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,907.40 / $9,907.40 / $9,907.40
| Facility | | $9,907.40 | $9,907.40 | $9,907.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,232.40 / $7,232.40 / $10,204.62
| Professional | | $7,232.40 | $7,232.40 | $10,204.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,941.43 / $12,941.43 / $39,943.72
| Professional | | $12,941.43 | $12,941.43 | $39,943.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,316.12 / $7,974.18 / $11,439.98
| Professional | | $5,316.12 | $7,974.18 | $11,439.98 |