- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,122.64 / $4,589.00 / $9,767.50
| Facility | | $2,122.64 | $4,589.00 | $9,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.02 / $2,300.06 / $3,515.60
| Professional | | $1,949.02 | $2,300.06 | $3,515.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,701.50 / $16,803.50 / $55,752.34
| Facility | | $7,701.50 | $16,803.50 | $55,752.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.37 / $2,676.61 / $4,583.31
| Professional | | $1,962.37 | $2,676.61 | $4,583.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.00 / $950.00 / $2,651.02
| Facility | | $895.00 | $950.00 | $2,651.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.30 / $3,012.62 / $4,942.32
| Professional | | $2,081.30 | $3,012.62 | $4,942.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,505.00 / $10,133.00 / $19,689.00
| Facility | | $4,505.00 | $10,133.00 | $19,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.95 / $2,759.41 / $4,766.60
| Professional | | $1,925.95 | $2,759.41 | $4,766.60 |