- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,551.00 / $5,503.00 / $10,651.00
| Facility | | $2,551.00 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.01 / $1,566.45 / $2,212.46
| Professional | | $1,249.01 | $1,566.45 | $2,212.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,948.00 / $14,105.00 / $28,800.00
| Facility | | $9,948.00 | $14,105.00 | $28,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.36 / $1,861.11 / $2,695.76
| Professional | | $1,505.36 | $1,861.11 | $2,695.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.87 / $2,069.57 / $2,731.89
| Professional | | $1,606.87 | $2,069.57 | $2,731.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,566.45 / $1,858.50 / $2,631.64
| Facility | | $1,566.45 | $1,858.50 | $2,631.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.70 / $2,044.35 / $2,628.45
| Professional | | $1,433.70 | $2,044.35 | $2,628.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.00 / $8,565.00 / $14,156.00
| Facility | | $2,506.00 | $8,565.00 | $14,156.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.95 / $2,320.69 / $4,251.96
| Professional | | $1,604.95 | $2,320.69 | $4,251.96 |