- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.80 / $2,363.60 / $10,773.00
| Facility | | $1,492.80 | $2,363.60 | $10,773.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.80 / $1,617.20 / $1,791.36
| Professional | | $1,492.80 | $1,617.20 | $1,791.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,249.56 / $1,749.38 / $9,354.87
| Facility | | $1,249.56 | $1,749.38 | $9,354.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.20 / $3,032.25 / $3,790.31
| Professional | | $2,859.20 | $3,032.25 | $3,790.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.07 / $1,492.80 / $2,948.03
| Professional | | $1,413.07 | $1,492.80 | $2,948.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,732.00 / $3,732.00 / $3,732.00
| Facility | | $3,732.00 | $3,732.00 | $3,732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.80 / $1,044.96 / $3,238.23
| Professional | | $870.80 | $1,044.96 | $3,238.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.78 / $1,492.80 / $1,492.80
| Professional | | $1,288.78 | $1,492.80 | $1,492.80 |