- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,079.46 / $9,332.54
| Professional | | $4,786.30 | $7,079.46 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $10,964.78 / $21,877.62
| Facility | | $9,120.11 | $10,964.78 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,511.38 / $9,332.54
| Professional | | $8,317.64 | $8,511.38 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,709.64 / $8,709.64
| Facility | | $4,897.79 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,912.51
| Professional | | $6,309.57 | $6,309.57 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,244.36 / $7,943.28
| Professional | | $6,760.83 | $7,244.36 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $9,332.54 / $16,218.10
| Facility | | $4,786.30 | $9,332.54 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,317.64 / $8,912.51
| Facility | | $4,466.84 | $8,317.64 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,495.41 / $8,511.38
| Professional | | $4,570.88 | $5,495.41 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58,884.37 / $58,884.37 / $58,884.37
| Facility | | $58,884.37 | $58,884.37 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72,443.60 / $72,443.60 / $102,329.30
| Professional | | $72,443.60 | $72,443.60 | $102,329.30 |