- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.68 / $6,918.68 / $6,918.68
| Facility | | $6,918.68 | $6,918.68 | $6,918.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,627.19 / $7,010.92 / $8,628.91
| Professional | | $5,627.19 | $7,010.92 | $8,628.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,927.01 / $8,719.52 / $10,463.42
| Professional | | $6,927.01 | $8,719.52 | $10,463.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.74 / $3,704.40 / $6,026.06
| Professional | | $3,148.74 | $3,704.40 | $6,026.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $7,433.65 / $7,433.65
| Facility | | $64.00 | $7,433.65 | $7,433.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,357.69 / $3,605.88 / $4,910.87
| Professional | | $2,357.69 | $3,605.88 | $4,910.87 |