- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,999.73 / $3,999.73 / $3,999.73
| Facility | | $3,999.73 | $3,999.73 | $3,999.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,999.73 / $3,999.73 / $6,733.35
| Professional | | $3,999.73 | $3,999.73 | $6,733.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,085.00 / $16,038.09 / $42,519.53
| Facility | | $5,085.00 | $16,038.09 | $42,519.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,996.14 / $6,337.86 / $8,939.67
| Professional | | $3,996.14 | $6,337.86 | $8,939.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,716.26 / $11,820.95 / $15,223.15
| Facility | | $9,716.26 | $11,820.95 | $15,223.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,994.29 / $8,122.35 / $8,122.35
| Professional | | $5,994.29 | $8,122.35 | $8,122.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,294.99 / $6,541.83 / $6,541.83
| Facility | | $5,294.99 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $11,723.63
| Professional | | $4,775.54 | $6,541.83 | $11,723.63 |
- 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
- $7,411.76 / $7,411.76 / $7,782.35
| Professional | | $7,411.76 | $7,411.76 | $7,782.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,089.06 / $5,089.06 / $5,089.06
| Professional | | $5,089.06 | $5,089.06 | $5,089.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,528.88 / $42,519.53 / $42,519.53
| Facility | | $20,528.88 | $42,519.53 | $42,519.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,575.87 / $4,893.30 / $8,939.67
| Professional | | $3,575.87 | $4,893.30 | $8,939.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,680.11 / $10,680.11 / $10,680.11
| Facility | | $10,680.11 | $10,680.11 | $10,680.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,975.80 / $4,893.30 / $8,010.09
| Professional | | $3,975.80 | $4,893.30 | $8,010.09 |