- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,705.06 / $4,236.41 / $8,340.00
| Facility | | $2,705.06 | $4,236.41 | $8,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.64 / $3,346.04 / $5,104.46
| Professional | | $2,808.64 | $3,346.04 | $5,104.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,584.00 / $21,162.00 / $55,752.34
| Facility | | $8,584.00 | $21,162.00 | $55,752.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,096.35 / $4,401.28 / $6,607.63
| Professional | | $3,096.35 | $4,401.28 | $6,607.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.00 / $950.00 / $3,686.20
| Facility | | $895.00 | $950.00 | $3,686.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,280.98 / $4,717.03 / $7,181.64
| Professional | | $3,280.98 | $4,717.03 | $7,181.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,041.01 / $9,642.00 / $19,106.00
| Facility | | $4,041.01 | $9,642.00 | $19,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.06 / $4,149.99 / $6,911.10
| Professional | | $2,902.06 | $4,149.99 | $6,911.10 |