- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,239.40 / $6,607.00 / $10,492.00
| Facility | | $2,239.40 | $6,607.00 | $10,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.90 / $2,239.40 / $3,415.52
| Professional | | $1,757.90 | $2,239.40 | $3,415.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,905.00 / $85,596.52 / $95,646.72
| Facility | | $12,905.00 | $85,596.52 | $95,646.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.93 / $3,092.17 / $3,538.82
| Professional | | $1,193.93 | $3,092.17 | $3,538.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.11 / $2,084.03 / $3,578.89
| Professional | | $1,521.11 | $2,084.03 | $3,578.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.77 / $1,907.77 / $2,241.07
| Professional | | $1,907.77 | $1,907.77 | $2,241.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $5,345.00 / $14,963.00
| Facility | | $3,275.00 | $5,345.00 | $14,963.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.56 / $2,167.19 / $4,270.71
| Professional | | $1,372.56 | $2,167.19 | $4,270.71 |