- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37,560.00 / $37,560.00 / $37,560.00
| Facility | | $37,560.00 | $37,560.00 | $37,560.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,040.56 / $12,528.28 / $13,629.32
| Professional | | $10,040.56 | $12,528.28 | $13,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,076.62 / $12,076.62 / $20,197.24
| Professional | | $12,076.62 | $12,076.62 | $20,197.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $13,280.27
| Facility | | $13,034.23 | $13,034.23 | $13,280.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,079.10 / $13,034.23 / $13,034.23
| Professional | | $11,079.10 | $13,034.23 | $13,034.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,361.75 / $13,123.61 / $19,107.43
| Professional | | $10,361.75 | $13,123.61 | $19,107.43 |