- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,280.34 / $9,202.00 / $15,171.00
| Facility | | $4,280.34 | $9,202.00 | $15,171.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.03 / $1,799.19 / $2,939.20
| Professional | | $1,660.03 | $1,799.19 | $2,939.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,659.00 / $14,202.00 / $18,574.58
| Facility | | $11,659.00 | $14,202.00 | $18,574.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.00 / $2,543.14 / $3,377.72
| Professional | | $1,244.00 | $2,543.14 | $3,377.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.19 / $2,130.40 / $3,450.30
| Professional | | $1,554.19 | $2,130.40 | $3,450.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.45 / $2,055.81 / $2,055.81
| Professional | | $1,910.45 | $2,055.81 | $2,055.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $6,137.00 / $16,193.00
| Facility | | $3,275.00 | $6,137.00 | $16,193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.14 / $1,915.85 / $3,675.16
| Professional | | $1,377.14 | $1,915.85 | $3,675.16 |