- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,449.00 / $6,977.00 / $13,982.00
| Facility | | $1,449.00 | $6,977.00 | $13,982.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.39 / $1,667.50 / $2,162.54
| Professional | | $1,394.39 | $1,667.50 | $2,162.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $12,484.00 / $54,020.00
| Facility | | $400.00 | $12,484.00 | $54,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,917.74 / $6,917.74 / $6,917.74
| Professional | | $6,917.74 | $6,917.74 | $6,917.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.08 / $7,491.98 / $7,947.84
| Professional | | $2,368.08 | $7,491.98 | $7,947.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $11,842.28
| Professional | | $40.00 | $40.00 | $11,842.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.00 / $5,279.00 / $8,957.00
| Facility | | $677.00 | $5,279.00 | $8,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.08 / $1,422.27 / $3,302.79
| Professional | | $905.08 | $1,422.27 | $3,302.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,992.45 / $1,992.45 / $1,992.45
| Professional | | $1,992.45 | $1,992.45 | $1,992.45 |