- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,147.25 / $5,147.25 / $5,147.25
| Facility | | $5,147.25 | $5,147.25 | $5,147.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,271.12 / $4,271.12 / $5,147.25
| Professional | | $4,271.12 | $4,271.12 | $5,147.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,865.07 / $9,945.41 / $12,431.76
| Professional | | $7,865.07 | $9,945.41 | $12,431.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,168.06 / $6,200.26 / $10,052.48
| Facility | | $5,168.06 | $6,200.26 | $10,052.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.66 / $3,285.48 / $10,776.38
| Professional | | $2,792.66 | $3,285.48 | $10,776.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.81 / $7,118.54 / $12,000.69
| Facility | | $3,453.81 | $7,118.54 | $12,000.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,453.81 / $9,582.65 / $12,000.69
| Professional | | $3,453.81 | $9,582.65 | $12,000.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,830.39 / $13,192.84 / $15,043.12
| Professional | | $7,830.39 | $13,192.84 | $15,043.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $2,792.66 / $7,228.06
| Professional | | $2,299.84 | $2,792.66 | $7,228.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.80 / $5,475.80 / $5,475.80
| Professional | | $5,475.80 | $5,475.80 | $5,475.80 |