- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93,325.43 / $93,325.43 / $93,325.43
| Facility | | $93,325.43 | $93,325.43 | $93,325.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $1,584.89
| Professional | | $912.01 | $1,148.15 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $37,153.52
| Facility | | $1,230.27 | $1,230.27 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $1,995.26
| Professional | | $1,071.52 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $2,691.53
| Facility | | $1,023.29 | $1,258.93 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $2,691.53
| Professional | | $1,445.44 | $1,778.28 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,606.93
| Facility | | $6,456.54 | $6,456.54 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,778.28 / $3,019.95
| Professional | | $1,000.00 | $1,778.28 | $3,019.95 |