- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,350.01 / $10,350.01 / $10,350.01
| Facility | | $10,350.01 | $10,350.01 | $10,350.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,769.37 / $11,307.38 / $11,307.38
| Professional | | $9,769.37 | $11,307.38 | $11,307.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,301.22 / $15,726.73 / $16,117.94
| Professional | | $13,301.22 | $15,726.73 | $16,117.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,650.25 / $15,806.75 / $19,875.82
| Professional | | $15,650.25 | $15,806.75 | $19,875.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,185.12 / $10,350.01 / $58,756.37
| Facility | | $6,185.12 | $10,350.01 | $58,756.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,534.64 / $8,301.95 / $11,334.82
| Professional | | $5,534.64 | $8,301.95 | $11,334.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,689.76 / $8,301.95 / $13,166.85
| Professional | | $3,689.76 | $8,301.95 | $13,166.85 |