- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,077.60 / $4,821.60 / $22,422.40
| Facility | | $2,077.60 | $4,821.60 | $22,422.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.60 / $2,940.00 / $3,332.00
| Professional | | $2,077.60 | $2,940.00 | $3,332.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,509.23 / $5,303.44 / $12,109.51
| Facility | | $3,509.23 | $5,303.44 | $12,109.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.00 / $5,135.20 / $7,142.24
| Professional | | $2,744.00 | $5,135.20 | $7,142.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,513.00 / $3,590.00 / $8,702.00
| Facility | | $2,513.00 | $3,590.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.00 / $2,744.00 / $2,744.00
| Professional | | $2,744.00 | $2,744.00 | $2,744.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.00 / $2,352.00 / $3,920.00
| Professional | | $1,568.00 | $2,352.00 | $3,920.00 |