- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,918.31 / $8,511.38
| Professional | | $6,025.60 | $6,918.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,709.64 / $10,471.29
| Professional | | $6,918.31 | $8,709.64 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $6,025.60
| Professional | | $3,162.28 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $7,413.10 / $7,413.10
| Facility | | $64.57 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $741.31 / $4,897.79
| Facility | | $426.58 | $741.31 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,630.78 / $4,897.79
| Professional | | $2,187.76 | $3,630.78 | $4,897.79 |