- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,488.00 / $4,080.32 / $7,582.43
| Facility | | $2,488.00 | $4,080.32 | $7,582.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.60 / $1,866.00 / $2,114.80
| Professional | | $1,741.60 | $1,866.00 | $2,114.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.84 / $2,985.60 / $6,157.80
| Facility | | $491.84 | $2,985.60 | $6,157.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.80 / $394.68 / $1,826.19
| Professional | | $358.80 | $394.68 | $1,826.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,738.54 / $4,184.50 / $7,034.82
| Facility | | $1,738.54 | $4,184.50 | $7,034.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.20 / $2,859.20 / $3,574.00
| Professional | | $2,859.20 | $2,859.20 | $3,574.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,239.19 / $2,239.19 / $2,239.19
| Facility | | $2,239.19 | $2,239.19 | $2,239.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.96 / $1,492.80 / $2,736.80
| Professional | | $1,044.96 | $1,492.80 | $2,736.80 |