- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,847.22 / $10,847.22 / $10,847.22
| Facility | | $10,847.22 | $10,847.22 | $10,847.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,563.92 / $7,962.32 / $10,847.22
| Professional | | $4,563.92 | $7,962.32 | $10,847.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,139.70 / $8,139.70 / $8,139.70
| Professional | | $8,139.70 | $8,139.70 | $8,139.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $7,447.14 / $17,568.75
| Professional | | $856.86 | $7,447.14 | $17,568.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,563.92 / $7,962.32 / $10,456.15
| Facility | | $4,563.92 | $7,962.32 | $10,456.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.96 / $3,805.15 / $5,712.40
| Professional | | $2,284.96 | $3,805.15 | $5,712.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,321.01 / $3,805.15 / $5,435.93
| Professional | | $2,321.01 | $3,805.15 | $5,435.93 |