- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,488.32 / $3,400.88 / $6,799.50
| Facility | | $2,488.32 | $3,400.88 | $6,799.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.32 / $2,813.52 / $4,694.39
| Professional | | $2,488.32 | $2,813.52 | $4,694.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $383.45 / $500.30 / $975.56
| Facility | | $383.45 | $500.30 | $975.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,714.63 / $3,393.28
| Professional | | $2,643.84 | $2,714.63 | $3,393.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.02 / $2,961.60 / $11,106.00
| Facility | | $1,388.02 | $2,961.60 | $11,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,468.00 / $2,592.00 / $3,110.40
| Professional | | $2,468.00 | $2,592.00 | $3,110.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.24 / $3,168.84 / $4,513.20
| Facility | | $2,637.24 | $3,168.84 | $4,513.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,964.04 / $2,964.04 / $2,964.04
| Professional | | $2,964.04 | $2,964.04 | $2,964.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,462.40 / $2,592.00 / $3,110.40
| Professional | | $2,462.40 | $2,592.00 | $3,110.40 |