- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,165.95 / $11,481.54
| Professional | | $5,128.61 | $6,165.95 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,302.69 / $64,565.42
| Facility | | $10,715.19 | $12,302.69 | $64,565.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,120.11 / $12,302.69
| Professional | | $5,623.41 | $9,120.11 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $15,488.17 / $20,892.96
| Facility | | $12,882.50 | $15,488.17 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $10,715.19 / $10,715.19
| Professional | | $7,762.47 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,128.31 / $8,317.64
| Facility | | $6,918.31 | $8,128.31 | $8,317.64 |
- 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
- $10,471.29 / $10,471.29 / $15,848.93
| Professional | | $10,471.29 | $10,471.29 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Professional | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,302.69 / $64,565.42
| Facility | | $10,715.19 | $12,302.69 | $64,565.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,332.54 / $13,489.63
| Professional | | $5,754.40 | $9,332.54 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.55 / $8,912.51 / $16,218.10
| Facility | | $9.55 | $8,912.51 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,511.38 / $10,471.29
| Professional | | $5,248.07 | $8,511.38 | $10,471.29 |