- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,406.58 / $10,406.58 / $10,406.58
| Facility | | $10,406.58 | $10,406.58 | $10,406.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,406.58 / $10,406.58 / $11,192.79
| Professional | | $10,406.58 | $10,406.58 | $11,192.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,794.63 / $26,644.57 / $37,139.39
| Facility | | $13,794.63 | $26,644.57 | $37,139.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,794.63 / $14,855.76 / $23,684.06
| Professional | | $13,794.63 | $14,855.76 | $23,684.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,847.37 / $13,847.37 / $24,497.70
| Facility | | $13,847.37 | $13,847.37 | $24,497.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,108.58 / $13,847.37 / $102,677.33
| Professional | | $10,108.58 | $13,847.37 | $102,677.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,366.76 / $13,366.90 / $17,646.13
| Professional | | $10,366.76 | $13,366.90 | $17,646.13 |