- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,912.51 / $15,135.61
| Professional | | $6,606.93 | $8,912.51 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $11,748.98 / $17,378.01
| Facility | | $10,000.00 | $11,748.98 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $11,748.98
| Professional | | $8,511.38 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $18,197.01 / $25,118.86
| Professional | | $11,220.18 | $18,197.01 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Professional | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $12,882.50 / $19,498.45
| Facility | | $7,585.78 | $12,882.50 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $8,912.51 / $14,125.38
| Professional | | $7,585.78 | $8,912.51 | $14,125.38 |