- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.00 / $4,387.00 / $5,308.70
| Facility | | $3,038.00 | $4,387.00 | $5,308.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,308.70 / $5,308.70 / $14,597.76
| Professional | | $5,308.70 | $5,308.70 | $14,597.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.84 / $3,223.04 / $4,636.48
| Professional | | $246.84 | $3,223.04 | $4,636.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,270.08 / $9,464.87 / $11,135.14
| Professional | | $6,270.08 | $9,464.87 | $11,135.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.00 / $2,446.00 / $13,847.00
| Facility | | $2,312.00 | $2,446.00 | $13,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,059.08 / $5,172.13 / $10,344.24
| Professional | | $4,059.08 | $5,172.13 | $10,344.24 |