- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,786.30 / $8,511.38
| Professional | | $3,467.37 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $9,332.54 / $42,657.95
| Facility | | $8,128.31 | $9,332.54 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,606.93 / $9,332.54
| Professional | | $3,981.07 | $6,606.93 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $15,848.93
| Facility | | $9,772.37 | $12,022.64 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,128.31 / $8,128.31
| Professional | | $6,025.60 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,606.93 / $6,606.93
| Facility | | $5,248.07 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,606.93
| Professional | | $4,786.30 | $4,786.30 | $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
- $7,943.28 / $7,943.28 / $12,302.69
| Professional | | $7,943.28 | $7,943.28 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $9,332.54 / $42,657.95
| Facility | | $8,128.31 | $9,332.54 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,918.31 / $10,232.93
| Professional | | $3,981.07 | $6,918.31 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.31 / $6,025.60 / $10,964.78
| Facility | | $6.31 | $6,025.60 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,025.60 / $7,943.28
| Professional | | $3,801.89 | $6,025.60 | $7,943.28 |