- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,025.60 / $10,471.29
| Professional | | $4,677.35 | $6,025.60 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $11,748.98 / $56,234.13
| Facility | | $10,232.93 | $11,748.98 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,511.38 / $11,748.98
| Professional | | $5,248.07 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $14,791.08 / $19,498.45
| Facility | | $12,302.69 | $14,791.08 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $10,000.00
| Professional | | $7,413.10 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,128.31 / $8,128.31
| Facility | | $5,754.40 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $8,128.31
| Professional | | $5,888.44 | $5,888.44 | $8,128.31 |
- 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
- $10,000.00 / $10,000.00 / $15,135.61
| Professional | | $10,000.00 | $10,000.00 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $11,748.98 / $56,234.13
| Facility | | $10,232.93 | $11,748.98 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,709.64 / $12,882.50
| Professional | | $5,248.07 | $8,709.64 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.32 / $7,943.28 / $14,454.40
| Facility | | $8.32 | $7,943.28 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,762.47 / $10,000.00
| Professional | | $4,897.79 | $7,762.47 | $10,000.00 |