- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,563.92 / $4,563.92 / $4,563.92
| Facility | | $4,563.92 | $4,563.92 | $4,563.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,563.92 / $7,112.72 / $13,482.32
| Professional | | $4,563.92 | $7,112.72 | $13,482.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $6,879.60 / $7,447.14
| Professional | | $856.86 | $6,879.60 | $7,447.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,563.92 / $7,482.56 / $12,693.56
| Facility | | $4,563.92 | $7,482.56 | $12,693.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.76 / $1,151.76 / $1,212.38
| Professional | | $1,151.76 | $1,151.76 | $1,212.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.12 / $582.51 / $4,368.81
| Professional | | $212.12 | $582.51 | $4,368.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.84 / $3,427.44 / $5,426.78
| Professional | | $2,904.84 | $3,427.44 | $5,426.78 |