- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,268.00 / $2,527.19 / $15,365.40
| Facility | | $2,268.00 | $2,527.19 | $15,365.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.19 / $2,527.19 / $2,592.00
| Professional | | $2,527.19 | $2,527.19 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,240.00 / $3,402.00 / $4,471.20
| Professional | | $3,240.00 | $3,402.00 | $4,471.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.38 / $7,981.74 / $18,473.83
| Facility | | $5,888.38 | $7,981.74 | $18,473.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.19 / $3,240.00 / $4,082.40
| Facility | | $2,527.19 | $3,240.00 | $4,082.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.80 / $1,944.00 / $2,950.38
| Professional | | $1,360.80 | $1,944.00 | $2,950.38 |