- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,653.92 / $7,360.44 / $12,702.50
| Facility | | $4,653.92 | $7,360.44 | $12,702.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,653.92 / $4,763.42 / $5,310.94
| Professional | | $4,653.92 | $4,763.42 | $5,310.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.20 / $4,886.60 / $9,697.44
| Professional | | $66.20 | $4,886.60 | $9,697.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,541.27 / $10,573.43 / $13,050.41
| Facility | | $7,541.27 | $10,573.43 | $13,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,354.14 / $6,354.14 / $6,354.14
| Professional | | $6,354.14 | $6,354.14 | $6,354.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,653.92 / $6,570.24 / $26,007.20
| Facility | | $4,653.92 | $6,570.24 | $26,007.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $27,266.50
| Professional | | $2,299.58 | $3,285.12 | $27,266.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $6,192.45
| Professional | | $2,299.58 | $3,285.12 | $6,192.45 |