- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.00 / $4,694.64 / $4,694.64
| Facility | | $3,038.00 | $4,694.64 | $4,694.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,284.72 / $4,694.64 / $10,195.01
| Professional | | $3,284.72 | $4,694.64 | $10,195.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.84 / $2,324.41 / $3,363.55
| Professional | | $246.84 | $2,324.41 | $3,363.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,657.41 / $5,529.30 / $9,943.65
| Professional | | $4,657.41 | $5,529.30 | $9,943.65 |
- 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
- $3,119.39 / $4,057.97 / $6,274.16
| Professional | | $3,119.39 | $4,057.97 | $6,274.16 |