- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,455.32 / $6,455.32 / $6,455.32
| Facility | | $6,455.32 | $6,455.32 | $6,455.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,455.32 / $7,094.78 / $63,182.40
| Professional | | $6,455.32 | $7,094.78 | $63,182.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $14,513.81
| Facility | | $14,513.81 | $14,513.81 | $14,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $14,513.81 / $15,472.44
| Professional | | $10,595.08 | $14,513.81 | $15,472.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,266.35 / $16,558.64 / $21,526.23
| Professional | | $10,266.35 | $16,558.64 | $21,526.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,861.41 / $22,150.67 / $22,150.67
| Facility | | $19,861.41 | $22,150.67 | $22,150.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,613.36 / $15,877.60 / $23,816.40
| Professional | | $12,613.36 | $15,877.60 | $23,816.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,028.41 / $9,999.21 / $14,345.15
| Professional | | $9,028.41 | $9,999.21 | $14,345.15 |