- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.73 / $3,133.82 / $4,807.35
| Facility | | $2,681.73 | $3,133.82 | $4,807.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.53 / $161.96 / $1,395.00
| Professional | | $142.53 | $161.96 | $1,395.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.36 / $851.36 / $1,378.16
| Facility | | $851.36 | $851.36 | $1,378.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,588.32 / $2,588.32 / $2,588.32
| Professional | | $2,588.32 | $2,588.32 | $2,588.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.36 / $851.36 / $1,378.16
| Facility | | $851.36 | $851.36 | $1,378.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.55 / $1,378.16 / $2,588.32
| Professional | | $1,084.55 | $1,378.16 | $2,588.32 |