- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,244.36 / $10,471.29
| Professional | | $5,128.61 | $7,244.36 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,589.25 / $18,620.87
| Facility | | $12,302.69 | $12,589.25 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $12,589.25 / $12,589.25
| Professional | | $10,000.00 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,302.68 / $46,773.51 / $112,201.85
| Facility | | $26,302.68 | $46,773.51 | $112,201.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,454.40 / $16,595.87 / $18,620.87
| Professional | | $14,454.40 | $16,595.87 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36,307.81 / $46,773.51 / $89,125.09
| Facility | | $36,307.81 | $46,773.51 | $89,125.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $19,952.62
| Professional | | $14,454.40 | $14,454.40 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $12,589.25 / $25,703.96
| Facility | | $5,370.32 | $12,589.25 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $13,182.57
| Professional | | $3,981.07 | $6,025.60 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.50 / $7,943.28 / $16,218.10
| Facility | | $95.50 | $7,943.28 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,309.57 / $14,791.08
| Professional | | $3,981.07 | $6,309.57 | $14,791.08 |