- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,209.52 / $6,209.52 / $6,209.52
| Facility | | $6,209.52 | $6,209.52 | $6,209.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,323.62 / $6,209.52 / $6,573.53
| Professional | | $5,323.62 | $6,209.52 | $6,573.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,390.02 / $7,750.19 / $9,703.20
| Professional | | $7,390.02 | $7,750.19 | $9,703.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $736.92 / $1,105.38 / $13,067.06
| Facility | | $736.92 | $1,105.38 | $13,067.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.28 / $1,196.35 / $13,720.41
| Professional | | $684.28 | $1,196.35 | $13,720.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $4,933.43
| Facility | | $4,933.43 | $4,933.43 | $4,933.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.42 / $4,933.43 / $10,012.70
| Professional | | $4,193.42 | $4,933.43 | $10,012.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.92 / $3,591.69 / $7,189.03
| Facility | | $430.92 | $3,591.69 | $7,189.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.40 / $4,968.60 / $7,802.28
| Professional | | $3,312.40 | $4,968.60 | $7,802.28 |