- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $8,912.51
| Facility | | $5,495.41 | $5,495.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $3,630.78 / $5,370.32
| Professional | | $588.84 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $2,630.27 / $3,548.13
| Professional | | $66.07 | $2,630.27 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $6,606.93
| Professional | | $5,495.41 | $5,495.41 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $3,630.78 / $5,370.32
| Professional | | $588.84 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,495.41 / $7,943.28
| Professional | | $3,311.31 | $5,495.41 | $7,943.28 |