- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,486.91 / $7,486.91 / $7,486.91
| Facility | | $7,486.91 | $7,486.91 | $7,486.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,823.10 / $5,495.71 / $7,486.91
| Professional | | $3,823.10 | $5,495.71 | $7,486.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,400.00 / $10,400.00 / $10,400.00
| Professional | | $10,400.00 | $10,400.00 | $10,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $10,804.69
| Professional | | $585.88 | $5,470.13 | $10,804.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,263.12 / $5,495.71 / $7,602.76
| Facility | | $4,263.12 | $5,495.71 | $7,602.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.59 / $2,763.88 / $4,948.56
| Professional | | $1,842.59 | $2,763.88 | $4,948.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.59 / $2,763.88 / $4,948.56
| Professional | | $1,842.59 | $2,763.88 | $4,948.56 |