- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,760.83 / $11,748.98
| Facility | | $3,981.07 | $6,760.83 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,265.80
| Professional | | $2,570.40 | $3,235.94 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,248.07 / $6,309.57
| Facility | | $4,677.35 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $8,317.64 / $17,782.79
| Facility | | $2,511.89 | $8,317.64 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,677.35 / $5,623.41
| Professional | | $4,466.84 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $5,248.07 / $7,244.36
| Professional | | $346.74 | $5,248.07 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $7,762.47
| Facility | | $3,890.45 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,890.45
| Professional | | $1,621.81 | $2,344.23 | $3,890.45 |