- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $6,760.83
| Facility | | $3,630.78 | $3,630.78 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,630.78 / $4,365.16
| Professional | | $2,398.83 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,442.29 / $48,977.88 / $125,892.54
| Facility | | $23,442.29 | $48,977.88 | $125,892.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $10,000.00 / $14,454.40
| Professional | | $9,549.93 | $10,000.00 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,378.01 / $17,378.01 / $17,378.01
| Professional | | $17,378.01 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,466.84 / $10,964.78
| Facility | | $2,344.23 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $14,125.38
| Professional | | $3,981.07 | $5,248.07 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43,651.58 / $44,668.36 / $60,255.96
| Facility | | $43,651.58 | $44,668.36 | $60,255.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,128.61 / $11,481.54
| Professional | | $3,981.07 | $5,128.61 | $11,481.54 |