- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,842.40 / $6,600.02 / $17,075.98
| Facility | | $2,842.40 | $6,600.02 | $17,075.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,503.17 / $2,842.40 / $4,711.85
| Professional | | $2,503.17 | $2,842.40 | $4,711.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,862.44 / $14,507.48 / $50,675.63
| Facility | | $6,862.44 | $14,507.48 | $50,675.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,364.59 / $8,126.40 / $8,126.40
| Professional | | $4,364.59 | $8,126.40 | $8,126.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $6,286.16
| Facility | | $4,536.46 | $4,536.46 | $6,286.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $6,657.75
| Professional | | $3,855.99 | $4,536.46 | $6,657.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.60 / $6,713.20 / $8,195.09
| Professional | | $5,168.60 | $6,713.20 | $8,195.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,465.74 / $7,465.74 / $7,465.74
| Professional | | $7,465.74 | $7,465.74 | $7,465.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.46 / $2,865.06 / $4,918.35
| Professional | | $2,186.46 | $2,865.06 | $4,918.35 |