- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,103.64 / $5,103.64 / $5,103.64
| Facility | | $5,103.64 | $5,103.64 | $5,103.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,103.64 / $5,103.64 / $8,924.59
| Professional | | $5,103.64 | $5,103.64 | $8,924.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,500.00 / $20,501.00 / $56,471.55
| Facility | | $6,500.00 | $20,501.00 | $56,471.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,296.61 / $8,400.37 / $11,407.01
| Professional | | $5,296.61 | $8,400.37 | $11,407.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,397.94 / $15,083.52 / $19,424.72
| Facility | | $12,397.94 | $15,083.52 | $19,424.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,648.67 / $10,364.11 / $10,364.11
| Professional | | $7,648.67 | $10,364.11 | $10,364.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,756.39 / $8,302.44 / $8,302.44
| Facility | | $6,756.39 | $8,302.44 | $8,302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $8,302.44 / $14,878.88
| Professional | | $6,060.78 | $8,302.44 | $14,878.88 |
- 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
- $9,457.41 / $9,457.41 / $9,930.28
| Professional | | $9,457.41 | $9,457.41 | $9,930.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,745.18 / $6,745.18 / $6,745.18
| Professional | | $6,745.18 | $6,745.18 | $6,745.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,053.87 / $56,471.55 / $56,471.55
| Facility | | $26,053.87 | $56,471.55 | $56,471.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,562.80 / $6,243.82 / $11,407.01
| Professional | | $4,562.80 | $6,243.82 | $11,407.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,985.68 / $6,243.82 / $11,407.01
| Professional | | $4,985.68 | $6,243.82 | $11,407.01 |