- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.00 / $5,318.34 / $8,413.00
| Facility | | $1,245.00 | $5,318.34 | $8,413.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,273.09 / $5,318.34 / $5,318.34
| Professional | | $4,273.09 | $5,318.34 | $5,318.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.06 / $2,200.36 / $3,292.44
| Professional | | $1,534.06 | $2,200.36 | $3,292.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.83 / $2,973.91 / $7,629.14
| Facility | | $1,083.83 | $2,973.91 | $7,629.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.83 / $1,083.83 / $1,083.83
| Professional | | $1,083.83 | $1,083.83 | $1,083.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,829.00 / $22,655.00 / $29,047.00
| Facility | | $10,829.00 | $22,655.00 | $29,047.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.26 / $1,312.79 / $3,349.85
| Professional | | $933.26 | $1,312.79 | $3,349.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42,398.84 / $42,398.84 / $66,194.92
| Facility | | $42,398.84 | $42,398.84 | $66,194.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37,834.72 / $45,335.48 / $45,335.48
| Professional | | $37,834.72 | $45,335.48 | $45,335.48 |