- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,258.02 / $6,258.02 / $6,258.02
| Facility | | $6,258.02 | $6,258.02 | $6,258.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,258.02 / $6,258.02 / $6,730.82
| Professional | | $6,258.02 | $6,258.02 | $6,730.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,363.62 / $17,228.98 / $22,333.87
| Facility | | $8,363.62 | $17,228.98 | $22,333.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,295.44 / $9,006.99 / $15,440.56
| Professional | | $8,295.44 | $9,006.99 | $15,440.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,077.06 / $9,077.06 / $15,459.78
| Facility | | $9,077.06 | $9,077.06 | $15,459.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,626.25 / $9,077.06 / $64,796.66
| Professional | | $6,626.25 | $9,077.06 | $64,796.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,969.15 / $8,527.35 / $10,611.55
| Professional | | $5,969.15 | $8,527.35 | $10,611.55 |