- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $9,120.11
| Professional | | $2,691.53 | $3,311.31 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,918.31 / $39,810.72
| Facility | | $6,025.60 | $6,918.31 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,011.87 / $6,918.31
| Professional | | $3,090.30 | $5,011.87 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $8,709.64 / $11,481.54
| Facility | | $7,244.36 | $8,709.64 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,888.44 / $5,888.44
| Professional | | $4,365.16 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,365.16 / $4,677.35
| Facility | | $3,890.45 | $4,365.16 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,365.16
| Professional | | $3,162.28 | $3,162.28 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $8,912.51
| Professional | | $5,888.44 | $5,888.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,918.31 / $39,810.72
| Facility | | $6,025.60 | $6,918.31 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,128.61 / $7,585.78
| Professional | | $3,090.30 | $5,128.61 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.01 / $4,677.35 / $8,511.38
| Facility | | $5.01 | $4,677.35 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,570.88 / $5,888.44
| Professional | | $2,884.03 | $4,570.88 | $5,888.44 |