- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,760.83 / $11,748.98
| Professional | | $5,495.41 | $6,760.83 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $13,182.57 / $66,069.34
| Facility | | $11,481.54 | $13,182.57 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,772.37 / $13,182.57
| Professional | | $6,025.60 | $9,772.37 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $16,982.44 / $22,387.21
| Facility | | $13,803.84 | $16,982.44 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,481.54 / $11,481.54
| Professional | | $8,511.38 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $9,120.11 / $9,120.11
| Facility | | $7,585.78 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $9,120.11
| Professional | | $6,606.93 | $6,606.93 | $9,120.11 |
- 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
- $11,220.18 / $11,220.18 / $17,378.01
| Professional | | $11,220.18 | $11,220.18 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Professional | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $13,182.57 / $66,069.34
| Facility | | $11,481.54 | $13,182.57 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $10,000.00 / $14,454.40
| Professional | | $6,165.95 | $10,000.00 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.77 / $9,120.11 / $16,595.87
| Facility | | $9.77 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,912.51 / $11,220.18
| Professional | | $5,623.41 | $8,912.51 | $11,220.18 |