- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,729.03 / $4,729.03 / $4,729.03
| Facility | | $4,729.03 | $4,729.03 | $4,729.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.84 / $1,612.45 / $3,699.15
| Professional | | $1,365.84 | $1,612.45 | $3,699.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,831.87 / $8,831.87 / $8,831.87
| Facility | | $8,831.87 | $8,831.87 | $8,831.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,435.00 / $9,636.95 / $15,563.68
| Professional | | $5,435.00 | $9,636.95 | $15,563.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.51 / $1,840.09 / $11,957.00
| Facility | | $1,261.51 | $1,840.09 | $11,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,435.00 / $7,337.25 / $7,609.00
| Professional | | $5,435.00 | $7,337.25 | $7,609.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,435.00 / $5,435.00 / $7,609.00
| Facility | | $5,435.00 | $5,435.00 | $7,609.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,276.40 / $2,276.40 / $8,831.87
| Facility | | $2,276.40 | $2,276.40 | $8,831.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.69 / $2,086.69 / $6,522.00
| Professional | | $2,086.69 | $2,086.69 | $6,522.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,685.12 / $9,142.23 / $17,127.02
| Professional | | $8,685.12 | $9,142.23 | $17,127.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $796.74 / $5,706.75
| Professional | | $796.74 | $796.74 | $5,706.75 |