- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $6,760.83
| Facility | | $1,513.56 | $1,513.56 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $2,951.21
| Professional | | $1,047.13 | $1,778.28 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $29,512.09 / $74,131.02
| Facility | | $16,218.10 | $29,512.09 | $74,131.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Professional | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $7,585.78 / $25,118.86
| Facility | | $1,949.84 | $7,585.78 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $10,471.29
| Professional | | $2,344.23 | $3,715.35 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $10,000.00 / $26,915.35
| Facility | | $1,584.89 | $10,000.00 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $7,244.36
| Professional | | $2,344.23 | $3,715.35 | $7,244.36 |