- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,715.19 / $15,488.17
| Professional | | $9,332.54 | $10,715.19 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $21,877.62 / $27,542.29
| Facility | | $11,748.98 | $21,877.62 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,748.98 / $20,892.96
| Professional | | $11,481.54 | $11,748.98 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $24,547.09 / $29,512.09
| Facility | | $19,952.62 | $24,547.09 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $13,803.84 / $21,877.62
| Facility | | $12,589.25 | $13,803.84 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $18,620.87
| Professional | | $10,000.00 | $10,000.00 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $15,135.61 / $16,982.44
| Facility | | $12,589.25 | $15,135.61 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,715.19 / $14,791.08
| Professional | | $6,309.57 | $10,715.19 | $14,791.08 |