- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,762.47 / $14,125.38
| Professional | | $6,760.83 | $7,762.47 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $16,218.10 / $77,624.71
| Facility | | $14,454.40 | $16,218.10 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,748.98 / $16,218.10
| Professional | | $7,244.36 | $11,748.98 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.01 / $20,892.96 / $27,542.29
| Facility | | $17,378.01 | $20,892.96 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $14,125.38 / $14,125.38
| Professional | | $10,471.29 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,000.00 / $11,220.18
| Facility | | $9,332.54 | $10,000.00 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $10,000.00
| Professional | | $7,244.36 | $7,244.36 | $10,000.00 |
- 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
- $14,125.38 / $14,125.38 / $21,379.62
| Professional | | $14,125.38 | $14,125.38 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Professional | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $16,218.10 / $77,624.71
| Facility | | $14,454.40 | $16,218.10 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $12,022.64 / $18,197.01
| Professional | | $7,244.36 | $12,022.64 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.48 / $10,964.78 / $19,498.45
| Facility | | $11.48 | $10,964.78 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,715.19 / $14,125.38
| Professional | | $6,760.83 | $10,715.19 | $14,125.38 |