- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,026.40 / $11,315.20 / $17,484.20
| Facility | | $6,026.40 | $11,315.20 | $17,484.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.64 / $4,763.95 / $5,475.80
| Professional | | $4,380.64 | $4,763.95 | $5,475.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,844.75 / $6,844.75 / $6,844.75
| Professional | | $6,844.75 | $6,844.75 | $6,844.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,840.60 / $8,969.36 / $12,416.45
| Facility | | $4,840.60 | $8,969.36 | $12,416.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.64 / $5,475.80 / $7,366.66
| Facility | | $4,380.64 | $5,475.80 | $7,366.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $27,269.48
| Professional | | $2,299.84 | $3,285.48 | $27,269.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $11,394.04
| Professional | | $2,299.84 | $3,285.48 | $11,394.04 |