- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $12,882.50
| Facility | | $9,120.11 | $9,120.11 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,677.35 / $9,772.37
| Professional | | $2,754.23 | $4,677.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $9,332.54 / $18,197.01
| Facility | | $5,011.87 | $9,332.54 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $5,128.61
| Professional | | $5,011.87 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,471.29 / $19,498.45
| Facility | | $3,890.45 | $10,471.29 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $9,772.37
| Facility | | $5,011.87 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,248.07 / $6,025.60
| Professional | | $4,677.35 | $5,248.07 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $9,772.37 / $18,197.01
| Facility | | $7,585.78 | $9,772.37 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,248.07
| Professional | | $4,265.80 | $4,265.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $5,011.87
| Professional | | $2,089.30 | $2,089.30 | $5,011.87 |