- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $10,232.93
| Facility | | $5,011.87 | $5,011.87 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $9,549.93
| Professional | | $3,467.37 | $5,011.87 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $19,498.45 / $69,183.10
| Facility | | $12,022.64 | $19,498.45 | $69,183.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $10,000.00
| Facility | | $6,606.93 | $6,606.93 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $10,232.93
| Professional | | $4,786.30 | $4,786.30 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $9,332.54 / $11,748.98
| Professional | | $7,413.10 | $9,332.54 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $13,182.57 / $13,182.57
| Professional | | $13,182.57 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,128.31 / $13,182.57
| Facility | | $5,248.07 | $8,128.31 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,011.87 / $7,585.78
| Professional | | $3,548.13 | $5,011.87 | $7,585.78 |