- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $9,746.61 / $9,746.61
| Facility | | $100.00 | $9,746.61 | $9,746.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.30 / $2,874.82 / $3,746.21
| Professional | | $2,586.30 | $2,874.82 | $3,746.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,769.10 / $15,307.77 / $29,108.25
| Facility | | $4,769.10 | $15,307.77 | $29,108.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,828.05 / $5,073.00 / $8,115.88
| Professional | | $2,828.05 | $5,073.00 | $8,115.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.60 / $5,337.81 / $8,667.62
| Professional | | $2,787.60 | $5,337.81 | $8,667.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,237.53 / $5,600.28 / $9,992.64
| Professional | | $3,237.53 | $5,600.28 | $9,992.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.00 / $3,360.00 / $7,448.00
| Facility | | $451.00 | $3,360.00 | $7,448.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,880.25 / $4,570.00 / $10,151.10
| Professional | | $2,880.25 | $4,570.00 | $10,151.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,124.83 / $2,337.31 / $2,974.76
| Professional | | $2,124.83 | $2,337.31 | $2,974.76 |