- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,915.12 / $7,915.12 / $7,915.12
| Facility | | $7,915.12 | $7,915.12 | $7,915.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,871.54 / $7,915.12 / $8,401.87
| Professional | | $6,871.54 | $7,915.12 | $8,401.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,970.30 / $6,278.93 / $8,288.18
| Professional | | $5,970.30 | $6,278.93 | $8,288.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.55 / $1,663.16 / $13,743.06
| Facility | | $895.55 | $1,663.16 | $13,743.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.58 / $1,535.22 / $13,493.19
| Professional | | $831.58 | $1,535.22 | $13,493.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.08 / $4,343.04 / $8,288.19
| Professional | | $705.08 | $4,343.04 | $8,288.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.19 / $4,065.36 / $5,726.60
| Professional | | $2,411.19 | $4,065.36 | $5,726.60 |