- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,128.61 / $9,120.11
| Professional | | $4,466.84 | $5,128.61 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $10,232.93 / $47,863.01
| Facility | | $9,772.37 | $10,232.93 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,943.28 / $10,715.19
| Professional | | $4,677.35 | $7,943.28 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $13,489.63 / $17,782.79
| Facility | | $11,748.98 | $13,489.63 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $9,120.11 / $9,120.11
| Professional | | $7,244.36 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,606.93
| Professional | | $4,897.79 | $4,897.79 | $6,606.93 |
- 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
- $9,120.11 / $9,120.11 / $13,803.84
| Professional | | $9,120.11 | $9,120.11 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Professional | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $10,232.93 / $47,863.01
| Facility | | $9,772.37 | $10,232.93 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,943.28 / $11,748.98
| Professional | | $4,677.35 | $7,943.28 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.41 / $6,918.31 / $12,589.25
| Facility | | $7.41 | $6,918.31 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $9,120.11
| Professional | | $4,365.16 | $6,918.31 | $9,120.11 |