- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.00 / $4,144.00 / $8,043.00
| Facility | | $1,614.00 | $4,144.00 | $8,043.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.06 / $2,546.06 / $2,546.06
| Professional | | $2,546.06 | $2,546.06 | $2,546.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,896.23 / $3,160.16 / $19,222.00
| Professional | | $2,896.23 | $3,160.16 | $19,222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.15 / $3,749.09 / $6,804.70
| Professional | | $2,493.15 | $3,749.09 | $6,804.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,700.85 / $5,606.82 / $5,606.82
| Professional | | $2,700.85 | $5,606.82 | $5,606.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,840.00 / $10,006.00 / $47,612.00
| Facility | | $7,840.00 | $10,006.00 | $47,612.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.59 / $4,757.97 / $6,788.34
| Professional | | $2,146.59 | $4,757.97 | $6,788.34 |