- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,555.38 / $7,555.38 / $7,555.38
| Facility | | $7,555.38 | $7,555.38 | $7,555.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,555.38 / $8,634.71 / $8,716.34
| Professional | | $7,555.38 | $8,634.71 | $8,716.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,812.54 / $9,812.54 / $9,812.54
| Facility | | $9,812.54 | $9,812.54 | $9,812.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,340.66 / $9,812.54 / $9,812.54
| Professional | | $8,340.66 | $9,812.54 | $9,812.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,310.92 / $11,501.68 / $81,836.25
| Facility | | $8,310.92 | $11,501.68 | $81,836.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,222.91 / $10,352.65 / $17,196.40
| Professional | | $5,222.91 | $10,352.65 | $17,196.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,222.91 / $8,393.33 / $12,169.09
| Professional | | $5,222.91 | $8,393.33 | $12,169.09 |