- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,814.40 / $7,814.40 / $7,814.40
| Facility | | $7,814.40 | $7,814.40 | $7,814.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,512.10 / $7,814.40 / $8,176.90
| Professional | | $5,512.10 | $7,814.40 | $8,176.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,600.00 / $2,600.00 / $2,600.00
| Professional | | $2,600.00 | $2,600.00 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,039.79 / $38,811.65 / $51,748.89
| Facility | | $3,039.79 | $38,811.65 | $51,748.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.45 / $10,236.85 / $14,547.10
| Professional | | $787.45 | $10,236.85 | $14,547.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.44 / $667.06 / $9,005.35
| Facility | | $548.44 | $667.06 | $9,005.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $8,210.00
| Professional | | $821.00 | $821.00 | $8,210.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,488.00 / $4,978.93 / $4,978.93
| Facility | | $4,488.00 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.31 / $8,456.90 / $14,873.44
| Professional | | $725.31 | $8,456.90 | $14,873.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.81 / $5,512.10 / $15,393.75
| Professional | | $1,282.81 | $5,512.10 | $15,393.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.09 / $1,701.35 / $7,376.20
| Professional | | $590.09 | $1,701.35 | $7,376.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,417.69 / $4,065.16 / $5,927.20
| Professional | | $2,417.69 | $4,065.16 | $5,927.20 |