- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,142.30 / $3,142.30 / $3,142.30
| Facility | | $3,142.30 | $3,142.30 | $3,142.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,142.30 / $3,142.30 / $5,171.78
| Professional | | $3,142.30 | $3,142.30 | $5,171.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,228.98 / $10,184.20 / $38,704.47
| Facility | | $3,228.98 | $10,184.20 | $38,704.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,102.28 / $4,835.42 / $7,023.28
| Professional | | $3,102.28 | $4,835.42 | $7,023.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,633.38 / $9,286.89 / $11,959.76
| Facility | | $7,633.38 | $9,286.89 | $11,959.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,709.28 / $6,381.16 / $6,381.16
| Professional | | $4,709.28 | $6,381.16 | $6,381.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,156.22 / $4,728.96 / $5,041.87
| Facility | | $4,156.22 | $4,728.96 | $5,041.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $8,475.00
| Professional | | $3,452.14 | $4,728.96 | $8,475.00 |
- 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
- $5,822.91 / $5,822.91 / $6,114.06
| Professional | | $5,822.91 | $5,822.91 | $6,114.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,908.81 / $3,908.81 / $3,908.81
| Professional | | $3,908.81 | $3,908.81 | $3,908.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,483.03 / $38,704.47 / $38,704.47
| Facility | | $16,483.03 | $38,704.47 | $38,704.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,809.31 / $3,844.31 / $7,023.28
| Professional | | $2,809.31 | $3,844.31 | $7,023.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,148.31 / $8,148.31 / $8,148.31
| Facility | | $8,148.31 | $8,148.31 | $8,148.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,048.83 / $4,009.62 / $6,392.80
| Professional | | $3,048.83 | $4,009.62 | $6,392.80 |