- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,305.00 / $9,221.50 / $18,133.00
| Facility | | $4,305.00 | $9,221.50 | $18,133.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.07 / $1,002.86 / $9,221.50
| Professional | | $277.07 | $1,002.86 | $9,221.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,098.00 / $12,905.00 / $17,206.00
| Facility | | $12,098.00 | $12,905.00 | $17,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.84 / $3,771.84 / $12,613.16
| Professional | | $466.84 | $3,771.84 | $12,613.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.00 / $1,060.56 / $11,032.06
| Professional | | $448.00 | $1,060.56 | $11,032.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,675.61 / $6,675.61 / $7,681.95
| Professional | | $6,675.61 | $6,675.61 | $7,681.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,706.00 / $11,710.00 / $21,600.00
| Facility | | $8,706.00 | $11,710.00 | $21,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,280.75 / $9,219.49 / $16,737.82
| Professional | | $5,280.75 | $9,219.49 | $16,737.82 |