- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,116.00 / $3,583.40 / $6,232.00
| Facility | | $3,116.00 | $3,583.40 | $6,232.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.48 / $3,583.40 / $3,583.40
| Professional | | $2,430.48 | $3,583.40 | $3,583.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.72 / $2,328.00 / $2,747.04
| Professional | | $1,916.72 | $2,328.00 | $2,747.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.40 / $2,531.75 / $6,744.58
| Facility | | $2,025.40 | $2,531.75 | $6,744.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.41 / $2,492.80 / $4,230.54
| Professional | | $1,349.41 | $2,492.80 | $4,230.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.72 / $1,308.72 / $1,875.44
| Professional | | $1,308.72 | $1,308.72 | $1,875.44 |