- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,233.27 / $5,233.27 / $5,233.27
| Facility | | $5,233.27 | $5,233.27 | $5,233.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,233.27 / $5,354.60 / $9,342.06
| Professional | | $5,233.27 | $5,354.60 | $9,342.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,610.50 / $20,849.52 / $63,837.40
| Facility | | $6,610.50 | $20,849.52 | $63,837.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,848.38 / $9,201.83 / $11,696.75
| Professional | | $5,848.38 | $9,201.83 | $11,696.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,712.83 / $15,466.62 / $19,918.08
| Facility | | $12,712.83 | $15,466.62 | $19,918.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,842.94 / $10,627.34 / $10,627.34
| Professional | | $7,842.94 | $10,627.34 | $10,627.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,927.98 / $8,121.18 / $8,396.83
| Facility | | $6,927.98 | $8,121.18 | $8,396.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $5,928.46 / $14,554.13
| Professional | | $5,928.46 | $5,928.46 | $14,554.13 |
- 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
- $9,697.62 / $9,697.62 / $10,182.50
| Professional | | $9,697.62 | $9,697.62 | $10,182.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,604.61 / $7,604.61 / $7,604.61
| Professional | | $7,604.61 | $7,604.61 | $7,604.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,485.03 / $63,837.40 / $63,837.40
| Facility | | $25,485.03 | $63,837.40 | $63,837.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,950.62 / $6,402.40 / $11,696.75
| Professional | | $4,950.62 | $6,402.40 | $11,696.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,201.95 / $6,840.20 / $11,696.75
| Professional | | $5,201.95 | $6,840.20 | $11,696.75 |