- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $14,454.40
| Facility | | $6,918.31 | $6,918.31 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,079.46 / $14,454.40
| Professional | | $5,495.41 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $26,915.35 / $97,723.72
| Facility | | $16,982.44 | $26,915.35 | $97,723.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $13,803.84
| Facility | | $9,120.11 | $9,120.11 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $14,125.38
| Professional | | $6,606.93 | $6,606.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $14,454.40 / $18,197.01
| Professional | | $11,748.98 | $14,454.40 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,197.01 / $18,197.01 / $18,197.01
| Professional | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $11,220.18 / $19,952.62
| Facility | | $8,128.31 | $11,220.18 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,079.46 / $10,471.29
| Professional | | $5,370.32 | $7,079.46 | $10,471.29 |