- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,500.74 / $7,500.74 / $7,500.74
| Facility | | $7,500.74 | $7,500.74 | $7,500.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,511.78 / $7,500.74 / $7,962.00
| Professional | | $6,511.78 | $7,500.74 | $7,962.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,375.04 / $8,913.34 / $11,141.67
| Professional | | $6,375.04 | $8,913.34 | $11,141.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.67 / $1,576.09 / $13,336.17
| Facility | | $848.67 | $1,576.09 | $13,336.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.05 / $1,454.86 / $13,093.70
| Professional | | $788.05 | $1,454.86 | $13,093.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.15 / $7,447.14 / $7,447.14
| Professional | | $668.15 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.96 / $3,852.52 / $5,435.93
| Professional | | $2,284.96 | $3,852.52 | $5,435.93 |