- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,565.95 / $5,565.95 / $8,227.93
| Facility | | $5,565.95 | $5,565.95 | $8,227.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,565.95 / $6,867.36 / $8,227.93
| Professional | | $5,565.95 | $6,867.36 | $8,227.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,013.46 / $6,684.62 / $9,358.74
| Professional | | $5,013.46 | $6,684.62 | $9,358.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,144.11 / $1,843.30 / $15,445.57
| Facility | | $1,144.11 | $1,843.30 | $15,445.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.24 / $2,097.55 / $24,884.52
| Professional | | $1,271.24 | $2,097.55 | $24,884.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.15 / $5,300.15 / $8,534.45
| Facility | | $5,300.15 | $5,300.15 | $8,534.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $5,300.15 / $5,459.15
| Professional | | $898.47 | $5,300.15 | $5,459.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.36 / $1,042.41 / $10,424.16
| Professional | | $623.36 | $1,042.41 | $10,424.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.13 / $3,909.24 / $5,887.27
| Professional | | $2,492.13 | $3,909.24 | $5,887.27 |