- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $756.00 / $2,694.00 / $4,118.39
| Facility | | $756.00 | $2,694.00 | $4,118.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.87 / $3,612.62 / $4,118.39
| Professional | | $2,391.87 | $3,612.62 | $4,118.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,085.52 / $26,974.83 / $57,409.30
| Facility | | $13,085.52 | $26,974.83 | $57,409.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,041.52 / $9,041.52 / $9,041.52
| Facility | | $9,041.52 | $9,041.52 | $9,041.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $488.00 / $675.00 / $13,016.91
| Facility | | $488.00 | $675.00 | $13,016.91 |
- 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
- $28,126.13 / $28,126.13 / $28,126.13
| Facility | | $28,126.13 | $28,126.13 | $28,126.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,070.43 / $4,159.05 / $7,143.25
| Professional | | $3,070.43 | $4,159.05 | $7,143.25 |