- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,844.00 / $8,212.79 / $8,212.79
| Facility | | $6,844.00 | $8,212.79 | $8,212.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,106.39 / $4,380.16 / $4,653.92
| Professional | | $4,106.39 | $4,380.16 | $4,653.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,391.52 / $30,798.00 / $147,830.40
| Facility | | $7,391.52 | $30,798.00 | $147,830.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,570.24 / $7,391.52 / $119,998.80
| Professional | | $6,570.24 | $7,391.52 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,448.60 / $6,570.24 / $16,424.23
| Facility | | $4,448.60 | $6,570.24 | $16,424.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,390.46 / $26,390.46 / $26,390.46
| Professional | | $26,390.46 | $26,390.46 | $26,390.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $2,737.60 / $7,939.04
| Professional | | $2,299.58 | $2,737.60 | $7,939.04 |