- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,918.31 / $9,120.11
| Facility | | $4,897.79 | $6,918.31 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $7,079.46 / $9,120.11
| Professional | | $794.33 | $7,079.46 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $16,982.44 / $16,982.44
| Facility | | $3,388.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,982.44 / $17,782.79
| Professional | | $10,471.29 | $16,982.44 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $4,897.79 / $9,120.11
| Facility | | $354.81 | $4,897.79 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $1,995.26 / $8,912.51
| Professional | | $141.25 | $1,995.26 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $12,589.25 / $31,622.78
| Facility | | $5,370.32 | $12,589.25 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $14,454.40
| Professional | | $741.31 | $1,000.00 | $14,454.40 |