- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,136.96 / $3,136.96 / $3,136.96
| Facility | | $3,136.96 | $3,136.96 | $3,136.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,136.96 / $3,136.96 / $5,211.68
| Professional | | $3,136.96 | $3,136.96 | $5,211.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.69 / $11,451.20 / $39,095.40
| Facility | | $3,630.69 | $11,451.20 | $39,095.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,118.19 / $4,884.26 / $7,011.37
| Professional | | $3,118.19 | $4,884.26 | $7,011.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,620.43 / $9,271.12 / $11,939.46
| Facility | | $7,620.43 | $9,271.12 | $11,939.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,701.28 / $6,370.33 / $6,370.33
| Professional | | $4,701.28 | $6,370.33 | $6,370.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,152.82 / $4,865.01 / $5,033.28
| Facility | | $4,152.82 | $4,865.01 | $5,033.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $4,865.01 / $8,718.75
| Professional | | $3,551.46 | $4,865.01 | $8,718.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,813.02 / $5,813.02 / $6,103.67
| Professional | | $5,813.02 | $5,813.02 | $6,103.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,938.99 / $3,938.99 / $3,938.99
| Professional | | $3,938.99 | $3,938.99 | $3,938.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,266.82 / $39,095.40 / $39,095.40
| Facility | | $15,266.82 | $39,095.40 | $39,095.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,804.55 / $3,837.78 / $7,011.37
| Professional | | $2,804.55 | $3,837.78 | $7,011.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,320.94 / $5,320.94 / $5,320.94
| Facility | | $5,320.94 | $5,320.94 | $5,320.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,079.62 / $3,616.97 / $6,172.96
| Professional | | $3,079.62 | $3,616.97 | $6,172.96 |