- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,240.00 / $2,809.00 / $5,923.00
| Facility | | $2,240.00 | $2,809.00 | $5,923.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,801.38 / $5,801.38 / $6,751.45
| Professional | | $5,801.38 | $5,801.38 | $6,751.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,526.00 / $9,098.00 / $15,073.00
| Facility | | $7,526.00 | $9,098.00 | $15,073.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.08 / $6,517.32 / $9,368.65
| Professional | | $1,085.08 | $6,517.32 | $9,368.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,293.00 / $20,115.00 / $20,115.00
| Facility | | $16,293.00 | $20,115.00 | $20,115.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,533.37 / $12,533.37 / $12,533.37
| Facility | | $12,533.37 | $12,533.37 | $12,533.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,163.00 / $6,491.00 / $14,434.00
| Facility | | $3,163.00 | $6,491.00 | $14,434.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.59 / $1,306.56 / $2,540.23
| Professional | | $875.59 | $1,306.56 | $2,540.23 |