- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,054.50 / $5,054.50 / $41,244.69
| Facility | | $5,054.50 | $5,054.50 | $41,244.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,054.50 / $5,054.50 / $5,256.68
| Professional | | $5,054.50 | $5,054.50 | $5,256.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,391.46 / $5,391.46 / $5,391.46
| Professional | | $5,391.46 | $5,391.46 | $5,391.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,951.40 / $11,389.46 / $24,500.01
| Facility | | $10,951.40 | $11,389.46 | $24,500.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,821.60 / $7,821.60 / $8,596.02
| Professional | | $7,821.60 | $7,821.60 | $8,596.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,750.23 / $13,699.04 / $13,699.04
| Professional | | $7,750.23 | $13,699.04 | $13,699.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,830.52 / $2,830.52 / $2,830.52
| Facility | | $2,830.52 | $2,830.52 | $2,830.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $4,043.60 / $10,715.53
| Professional | | $2,830.52 | $4,043.60 | $10,715.53 |