- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $13,803.84 / $13,803.84
| Facility | | $12,302.69 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $8,317.64 / $13,803.84
| Professional | | $6,309.57 | $8,317.64 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,848.93 / $20,892.96 / $22,908.68
| Professional | | $15,848.93 | $20,892.96 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $20,892.96
| Professional | | $16,982.44 | $16,982.44 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $13,803.84 / $74,131.02
| Facility | | $6,918.31 | $13,803.84 | $74,131.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,549.93 / $16,982.44
| Professional | | $6,025.60 | $9,549.93 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $23,442.29 / $23,442.29
| Facility | | $9,549.93 | $23,442.29 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $10,000.00 / $16,982.44
| Professional | | $5,623.41 | $10,000.00 | $16,982.44 |