- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,549.93 / $13,803.84
| Professional | | $6,760.83 | $9,549.93 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,748.98 / $12,302.69
| Facility | | $9,549.93 | $11,748.98 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,762.47 / $11,481.54
| Professional | | $3,981.07 | $7,762.47 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,238.72
| Facility | | $2,187.76 | $2,187.76 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $12,589.25 / $12,589.25
| Professional | | $8,912.51 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $12,022.64
| Facility | | $11,220.18 | $11,220.18 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $11,220.18 / $26,302.68
| Professional | | $1,348.96 | $11,220.18 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $15,848.93 / $15,848.93
| Professional | | $4,897.79 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Professional | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,748.98 / $12,302.69
| Facility | | $9,549.93 | $11,748.98 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,762.47 / $11,748.98
| Professional | | $3,981.07 | $7,762.47 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.13 / $1,023.29 / $7,762.47
| Facility | | $8.13 | $1,023.29 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,456.54 / $15,848.93
| Professional | | $3,981.07 | $6,456.54 | $15,848.93 |