- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $13,530.20
| Facility | | $2,480.40 | $2,480.40 | $13,530.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $6,765.12
| Professional | | $2,480.40 | $2,480.40 | $6,765.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,864.64 / $8,864.64 / $8,864.64
| Facility | | $8,864.64 | $8,864.64 | $8,864.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,998.40 / $11,664.00 / $11,664.00
| Professional | | $6,998.40 | $11,664.00 | $11,664.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,054.39 / $5,863.10 / $13,950.14
| Facility | | $5,054.39 | $5,863.10 | $13,950.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,541.49 / $6,687.44 / $11,607.77
| Professional | | $3,541.49 | $6,687.44 | $11,607.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.92 / $4,665.60 / $7,776.00
| Professional | | $3,265.92 | $4,665.60 | $7,776.00 |