- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,166.91 / $14,047.10 / $18,651.70
| Facility | | $9,166.91 | $14,047.10 | $18,651.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,341.25 / $6,341.25 / $6,341.25
| Professional | | $6,341.25 | $6,341.25 | $6,341.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.88 / $8,455.00 / $20,292.00
| Facility | | $2,747.88 | $8,455.00 | $20,292.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $208.00 / $4,379.68
| Professional | | $208.00 | $208.00 | $4,379.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.11 / $8,133.71 / $30,611.33
| Facility | | $3,340.11 | $8,133.71 | $30,611.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,298.34 / $10,298.34 / $12,338.57
| Professional | | $10,298.34 | $10,298.34 | $12,338.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.75 / $8,455.00 / $8,877.75
| Professional | | $2,113.75 | $8,455.00 | $8,877.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $5,880.00
| Professional | | $1,543.50 | $2,205.00 | $5,880.00 |