- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,943.28 / $9,120.11
| Professional | | $7,413.10 | $7,943.28 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $12,022.64
| Professional | | $10,232.93 | $10,232.93 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $10,000.00
| Professional | | $8,317.64 | $8,317.64 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $24,547.09 / $33,884.42
| Professional | | $11,220.18 | $24,547.09 | $33,884.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $25,703.96 / $25,703.96
| Facility | | $25,703.96 | $25,703.96 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,709.64 / $12,882.50
| Professional | | $5,623.41 | $8,709.64 | $12,882.50 |