- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,542.80 / $4,273.56 / $7,470.40
| Facility | | $1,542.80 | $4,273.56 | $7,470.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.80 / $1,542.80 / $1,908.20
| Professional | | $1,320.80 | $1,542.80 | $1,908.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,598.40 / $5,846.40 / $9,795.56
| Facility | | $2,598.40 | $5,846.40 | $9,795.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $852.60 / $2,030.00
| Professional | | $852.60 | $852.60 | $2,030.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,161.16 / $1,359.09 / $6,201.65
| Facility | | $1,161.16 | $1,359.09 | $6,201.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.66 / $1,086.59 / $3,047.81
| Professional | | $943.66 | $1,086.59 | $3,047.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,542.80 / $2,030.00 / $2,842.00
| Facility | | $1,542.80 | $2,030.00 | $2,842.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.00 / $2,882.60 / $4,872.00
| Professional | | $1,624.00 | $2,882.60 | $4,872.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $852.60 / $1,502.20
| Professional | | $852.60 | $852.60 | $1,502.20 |