- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,446.47 / $11,446.47 / $11,446.47
| Facility | | $11,446.47 | $11,446.47 | $11,446.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,816.16 / $8,402.20 / $11,446.47
| Professional | | $4,816.16 | $8,402.20 | $11,446.47 |
- 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
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.20 / $5,109.46 / $18,539.06
| Professional | | $904.20 | $5,109.46 | $18,539.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,816.16 / $8,402.20 / $11,033.74
| Facility | | $4,816.16 | $8,402.20 | $11,033.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.19 / $4,015.34 / $6,028.00
| Professional | | $2,411.19 | $4,015.34 | $6,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.03 / $4,255.04 / $5,736.20
| Professional | | $2,508.03 | $4,255.04 | $5,736.20 |