- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,372.83 / $5,372.83 / $5,372.83
| Facility | | $5,372.83 | $5,372.83 | $5,372.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,372.83 / $5,372.83 / $9,325.67
| Professional | | $5,372.83 | $5,372.83 | $9,325.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,850.00 / $21,604.90 / $58,756.37
| Facility | | $6,850.00 | $21,604.90 | $58,756.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,534.64 / $8,777.90 / $12,008.67
| Professional | | $5,534.64 | $8,777.90 | $12,008.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,051.86 / $15,879.08 / $20,449.25
| Facility | | $13,051.86 | $15,879.08 | $20,449.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,052.09 / $10,910.76 / $10,910.76
| Professional | | $8,052.09 | $10,910.76 | $10,910.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,112.73 / $8,732.85 / $8,732.85
| Facility | | $7,112.73 | $8,732.85 | $8,732.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,374.98 / $8,732.85 / $15,650.25
| Professional | | $6,374.98 | $8,732.85 | $15,650.25 |
- 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
- $9,956.24 / $9,956.24 / $10,454.04
| Professional | | $9,956.24 | $9,956.24 | $10,454.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,048.32 / $7,048.32 / $7,048.32
| Professional | | $7,048.32 | $7,048.32 | $7,048.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,404.53 / $58,756.37 / $58,756.37
| Facility | | $27,404.53 | $58,756.37 | $58,756.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,803.47 / $6,573.14 / $12,008.67
| Professional | | $4,803.47 | $6,573.14 | $12,008.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,544.86 / $5,544.86 / $5,544.86
| Facility | | $5,544.86 | $5,544.86 | $5,544.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,340.67 / $7,040.89 / $12,008.67
| Professional | | $5,340.67 | $7,040.89 | $12,008.67 |