- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,351.43 / $9,351.43 / $9,351.43
| Facility | | $9,351.43 | $9,351.43 | $9,351.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,147.24 / $9,351.43 / $12,263.06
| Professional | | $9,147.24 | $9,351.43 | $12,263.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,192.81 / $9,638.60 / $22,136.75
| Professional | | $8,192.81 | $9,638.60 | $22,136.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.13 / $1,741.07 / $9,811.29
| Facility | | $981.13 | $1,741.07 | $9,811.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.96 / $1,741.07 / $9,967.91
| Professional | | $833.96 | $1,741.07 | $9,967.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,922.50 / $10,694.63 / $11,688.69
| Facility | | $6,922.50 | $10,694.63 | $11,688.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,090.44 / $10,694.63 / $14,476.60
| Professional | | $9,090.44 | $10,694.63 | $14,476.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,922.50 / $10,694.63 / $10,694.63
| Facility | | $6,922.50 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,090.44 / $10,694.63 / $10,694.63
| Professional | | $9,090.44 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.07 / $1,162.81 / $7,994.38
| Professional | | $545.07 | $1,162.81 | $7,994.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,413.13 / $5,450.72 / $7,416.01
| Professional | | $3,413.13 | $5,450.72 | $7,416.01 |