- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $13,996.80
| Facility | | $2,480.40 | $2,480.40 | $13,996.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.40 / $7,309.44 / $7,776.00
| Professional | | $2,480.40 | $7,309.44 | $7,776.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,704.82 / $15,668.64 / $17,496.00
| Professional | | $11,704.82 | $15,668.64 | $17,496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,935.26 / $8,935.26 / $13,117.37
| Professional | | $8,935.26 | $8,935.26 | $13,117.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.40 / $4,665.60 / $11,664.00
| Facility | | $2,480.40 | $4,665.60 | $11,664.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,965.76 / $9,331.20 / $15,552.00
| Professional | | $3,965.76 | $9,331.20 | $15,552.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.92 / $7,931.52 / $13,219.20
| Professional | | $3,265.92 | $7,931.52 | $13,219.20 |