- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,194.00 / $5,594.00 / $9,523.33
| Facility | | $4,194.00 | $5,594.00 | $9,523.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,651.14 / $9,394.46 / $9,523.33
| Professional | | $2,651.14 | $9,394.46 | $9,523.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,720.36 / $7,874.27 / $21,592.00
| Facility | | $2,720.36 | $7,874.27 | $21,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,868.02 / $9,835.02 / $13,619.29
| Professional | | $7,868.02 | $9,835.02 | $13,619.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.93 / $1,922.61 / $2,809.97
| Professional | | $1,478.93 | $1,922.61 | $2,809.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,303.00 / $10,242.00 / $20,037.00
| Facility | | $2,303.00 | $10,242.00 | $20,037.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,993.93 / $13,457.91 / $20,328.81
| Professional | | $4,993.93 | $13,457.91 | $20,328.81 |