- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,456.54 / $12,882.50
| Professional | | $5,011.87 | $6,456.54 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,589.25 / $58,884.37
| Facility | | $10,964.78 | $12,589.25 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,912.51 / $12,589.25
| Professional | | $5,495.41 | $8,912.51 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $15,848.93 / $21,379.62
| Facility | | $13,182.57 | $15,848.93 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,964.78 / $10,964.78
| Professional | | $8,128.31 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $8,709.64 / $8,709.64
| Facility | | $7,079.46 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,709.64
| Professional | | $6,309.57 | $6,309.57 | $8,709.64 |
- 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
- $10,715.19 / $10,715.19 / $16,218.10
| Professional | | $10,715.19 | $10,715.19 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Professional | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,589.25 / $58,884.37
| Facility | | $10,964.78 | $12,589.25 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,332.54 / $13,803.84
| Professional | | $5,495.41 | $9,332.54 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.91 / $8,317.64 / $15,135.61
| Facility | | $8.91 | $8,317.64 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,317.64 / $10,715.19
| Professional | | $5,248.07 | $8,317.64 | $10,715.19 |