- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,703.46 / $3,703.46 / $3,703.46
| Facility | | $3,703.46 | $3,703.46 | $3,703.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,703.46 / $3,906.04 / $6,744.80
| Professional | | $3,703.46 | $3,906.04 | $6,744.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,583.69 / $22,637.31 / $40,507.83
| Facility | | $7,583.69 | $22,637.31 | $40,507.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.38 / $6,296.59 / $8,277.52
| Professional | | $3,870.38 | $6,296.59 | $8,277.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,255.02 / $10,945.37 / $14,095.57
| Facility | | $9,255.02 | $10,945.37 | $14,095.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,363.53 / $7,124.90 / $7,124.90
| Professional | | $6,363.53 | $7,124.90 | $7,124.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,898.43 / $6,042.00 / $6,042.00
| Facility | | $4,898.43 | $6,042.00 | $6,042.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,410.66 / $6,042.00 / $10,068.00
| Professional | | $4,410.66 | $6,042.00 | $10,068.00 |
- 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
- $6,862.77 / $6,862.77 / $7,205.91
| Professional | | $6,862.77 | $6,862.77 | $7,205.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,902.52 / $5,902.52 / $5,902.52
| Professional | | $5,902.52 | $5,902.52 | $5,902.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,629.34 / $40,507.83 / $40,507.83
| Facility | | $17,629.34 | $40,507.83 | $40,507.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.01 / $4,530.84 / $8,277.52
| Professional | | $3,311.01 | $4,530.84 | $8,277.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,681.31 / $4,545.70 / $8,277.52
| Professional | | $3,681.31 | $4,545.70 | $8,277.52 |