- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,992.63 / $5,992.63 / $7,191.16
| Facility | | $5,992.63 | $5,992.63 | $7,191.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,529.42 / $4,650.14 / $5,992.63
| Professional | | $4,529.42 | $4,650.14 | $5,992.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,642.84 / $10,642.84 / $12,616.02
| Facility | | $10,642.84 | $10,642.84 | $12,616.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.53 / $5,623.53 / $5,901.24
| Professional | | $5,623.53 | $5,623.53 | $5,901.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $7,261.93
| Facility | | $7,261.93 | $7,261.93 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $7,261.93
| Professional | | $5,301.21 | $5,301.21 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,617.03 / $8,617.03 / $26,596.46
| Professional | | $8,617.03 | $8,617.03 | $26,596.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,539.73 / $5,309.60 / $8,945.81
| Professional | | $3,539.73 | $5,309.60 | $8,945.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,971.14 / $8,768.25 / $10,000.00
| Professional | | $7,971.14 | $8,768.25 | $10,000.00 |