- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,105.76 / $6,284.00 / $13,151.00
| Facility | | $2,105.76 | $6,284.00 | $13,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.10 / $1,624.92 / $2,105.76
| Professional | | $1,042.10 | $1,624.92 | $2,105.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,883.22 / $31,922.33 / $63,728.92
| Facility | | $16,883.22 | $31,922.33 | $63,728.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.83 / $1,596.28 / $2,630.38
| Professional | | $1,356.83 | $1,596.28 | $2,630.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.90 / $2,424.21 / $11,186.00
| Facility | | $1,066.90 | $2,424.21 | $11,186.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.46 / $3,371.33 / $12,233.12
| Professional | | $2,070.46 | $3,371.33 | $12,233.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.00 / $3,233.00 / $11,343.00
| Facility | | $1,185.00 | $3,233.00 | $11,343.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.46 / $3,069.65 / $4,812.89
| Professional | | $2,070.46 | $3,069.65 | $4,812.89 |