- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Professional | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $56,234.13
| Facility | | $5,623.41 | $5,623.41 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $5,128.61 / $5,623.41
| Professional | | $489.78 | $5,128.61 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,413.10 / $9,332.54
| Professional | | $7,244.36 | $7,413.10 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Professional | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $588.84 / $1,122.02
| Professional | | $537.03 | $588.84 | $1,122.02 |