- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,661.45 / $6,661.45 / $6,661.45
| Facility | | $6,661.45 | $6,661.45 | $6,661.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,661.45 / $7,613.09 / $8,036.95
| Professional | | $6,661.45 | $7,613.09 | $8,036.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,907.40 / $9,907.40 / $9,907.40
| Facility | | $9,907.40 | $9,907.40 | $9,907.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,232.40 / $9,907.40 / $9,907.40
| Professional | | $7,232.40 | $9,907.40 | $9,907.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,656.56 / $9,324.77 / $75,302.32
| Facility | | $4,656.56 | $9,324.77 | $75,302.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,808.64 / $9,531.50 / $15,161.77
| Professional | | $4,808.64 | $9,531.50 | $15,161.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,808.64 / $7,400.26 / $10,867.72
| Professional | | $4,808.64 | $7,400.26 | $10,867.72 |