- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,942.40 / $8,662.71 / $24,640.00
| Facility | | $3,942.40 | $8,662.71 | $24,640.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,790.40 / $6,814.02 / $15,910.40
| Facility | | $5,790.40 | $6,814.02 | $15,910.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.00 / $2,288.00 / $2,583.67
| Professional | | $1,408.00 | $2,288.00 | $2,583.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,356.06 / $12,868.11 / $15,441.71
| Facility | | $6,356.06 | $12,868.11 | $15,441.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.00 / $4,044.92 / $5,056.14
| Professional | | $2,816.00 | $4,044.92 | $5,056.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,777.34 / $6,255.74 / $12,523.81
| Professional | | $4,777.34 | $6,255.74 | $12,523.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.40 / $2,112.00 / $2,112.00
| Professional | | $1,478.40 | $2,112.00 | $2,112.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.38 / $2,891.22 / $3,679.73
| Professional | | $2,628.38 | $2,891.22 | $3,679.73 |