- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,413.10 / $12,882.50
| Professional | | $5,623.41 | $7,413.10 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $10,000.00 / $14,791.08
| Facility | | $8,709.64 | $10,000.00 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $10,000.00
| Professional | | $7,244.36 | $7,244.36 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $15,488.17 / $21,379.62
| Professional | | $9,549.93 | $15,488.17 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Professional | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,964.78 / $16,595.87
| Facility | | $6,606.93 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,585.78 / $12,022.64
| Professional | | $6,456.54 | $7,585.78 | $12,022.64 |