- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,284.04 / $4,721.00 / $8,828.00
| Facility | | $2,284.04 | $4,721.00 | $8,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.15 / $3,670.31 / $4,319.49
| Professional | | $2,546.15 | $3,670.31 | $4,319.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,334.00 / $9,223.00 / $16,253.00
| Facility | | $4,334.00 | $9,223.00 | $16,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.49 / $1,494.43 / $2,355.12
| Professional | | $1,237.49 | $1,494.43 | $2,355.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $4,393.89 / $12,590.58
| Facility | | $680.00 | $4,393.89 | $12,590.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,665.76 / $6,665.76 / $6,665.76
| Professional | | $6,665.76 | $6,665.76 | $6,665.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,501.46 / $16,612.01 / $23,875.82
| Facility | | $14,501.46 | $16,612.01 | $23,875.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,703.27 / $4,453.09 / $7,768.59
| Professional | | $3,703.27 | $4,453.09 | $7,768.59 |