- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,758.55 / $11,758.55 / $11,758.55
| Facility | | $11,758.55 | $11,758.55 | $11,758.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,947.43 / $8,631.28 / $11,758.55
| Professional | | $4,947.43 | $8,631.28 | $11,758.55 |
- 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
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.85 / $8,072.81 / $19,045.31
| Professional | | $928.85 | $8,072.81 | $19,045.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,947.43 / $8,631.28 / $11,334.47
| Facility | | $4,947.43 | $8,631.28 | $11,334.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.92 / $4,124.77 / $6,192.33
| Professional | | $2,476.92 | $4,124.77 | $6,192.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,516.01 / $4,371.04 / $6,192.33
| Professional | | $2,516.01 | $4,371.04 | $6,192.33 |