- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.40 / $6,842.88 / $29,859.80
| Facility | | $2,480.40 | $6,842.88 | $29,859.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $7,776.00
| Professional | | $2,480.40 | $2,480.40 | $7,776.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,905.35 / $5,467.49 / $29,238.16
| Facility | | $3,905.35 | $5,467.49 | $29,238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,884.16 / $8,177.79 / $11,347.77
| Professional | | $3,884.16 | $8,177.79 | $11,347.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,665.60 / $4,665.60 / $6,796.84
| Professional | | $4,665.60 | $4,665.60 | $6,796.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $70.00
| Professional | | $40.00 | $40.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.60 / $3,265.92 / $12,183.90
| Professional | | $2,721.60 | $3,265.92 | $12,183.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,665.60 / $4,665.60 / $4,665.60
| Professional | | $4,665.60 | $4,665.60 | $4,665.60 |