- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,977.42 / $4,977.42 / $4,977.42
| Facility | | $4,977.42 | $4,977.42 | $4,977.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,977.42 / $4,977.42 / $8,238.81
| Professional | | $4,977.42 | $4,977.42 | $8,238.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,102.00 / $19,245.71 / $56,163.20
| Facility | | $6,102.00 | $19,245.71 | $56,163.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,253.60 / $8,214.29 / $11,124.90
| Professional | | $5,253.60 | $8,214.29 | $11,124.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,091.31 / $14,710.46 / $18,944.30
| Facility | | $12,091.31 | $14,710.46 | $18,944.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,459.52 / $10,107.78 / $10,107.78
| Professional | | $7,459.52 | $10,107.78 | $10,107.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,689.29 / $8,136.27 / $8,136.27
| Facility | | $5,689.29 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,939.48 / $8,136.27 / $14,581.13
| Professional | | $5,939.48 | $8,136.27 | $14,581.13 |
- 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
- $9,223.50 / $9,223.50 / $9,684.68
| Professional | | $9,223.50 | $9,223.50 | $9,684.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,690.42 / $6,690.42 / $6,690.42
| Professional | | $6,690.42 | $6,690.42 | $6,690.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,532.39 / $56,163.20 / $56,163.20
| Facility | | $25,532.39 | $56,163.20 | $56,163.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,449.96 / $6,089.40 / $11,124.90
| Professional | | $4,449.96 | $6,089.40 | $11,124.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,945.21 / $6,089.40 / $11,164.01
| Professional | | $4,945.21 | $6,089.40 | $11,164.01 |