- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,191.44 / $6,191.44 / $6,191.44
| Facility | | $6,191.44 | $6,191.44 | $6,191.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,191.44 / $9,649.01 / $18,289.91
| Professional | | $6,191.44 | $9,649.01 | $18,289.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.40 / $8,587.24 / $10,102.62
| Professional | | $1,162.40 | $8,587.24 | $10,102.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,191.44 / $10,225.07 / $17,219.84
| Facility | | $6,191.44 | $10,225.07 | $17,219.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.46 / $1,562.46 / $1,644.69
| Professional | | $1,562.46 | $1,562.46 | $1,644.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.41 / $790.21 / $5,926.65
| Professional | | $493.41 | $790.21 | $5,926.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,298.92 / $4,649.60 / $8,525.29
| Professional | | $4,298.92 | $4,649.60 | $8,525.29 |