- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,732.77 / $6,732.77 / $6,732.77
| Facility | | $6,732.77 | $6,732.77 | $6,732.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,764.17 / $6,732.77 / $6,932.78
| Professional | | $5,764.17 | $6,732.77 | $6,932.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,662.05 / $4,662.05 / $6,153.90
| Professional | | $4,662.05 | $4,662.05 | $6,153.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.63 / $1,403.31 / $11,874.18
| Facility | | $755.63 | $1,403.31 | $11,874.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.66 / $1,295.35 / $11,658.28
| Professional | | $701.66 | $1,295.35 | $11,658.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.51 / $7,608.68 / $7,608.68
| Professional | | $631.51 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.21 / $3,591.56 / $5,581.88
| Professional | | $2,238.21 | $3,591.56 | $5,581.88 |