- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,168.69 / $7,244.36
| Professional | | $3,548.13 | $4,168.69 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,128.31 / $40,738.03
| Facility | | $7,943.28 | $8,128.31 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,456.54 / $9,772.37
| Professional | | $3,801.89 | $6,456.54 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,964.78 / $14,454.40
| Facility | | $9,332.54 | $10,964.78 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,079.46 / $7,079.46
| Professional | | $6,165.95 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,786.30
| Professional | | $4,073.80 | $4,073.80 | $4,786.30 |
- 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
- $7,413.10 / $7,413.10 / $11,220.18
| Professional | | $7,413.10 | $7,413.10 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,128.31 / $40,738.03
| Facility | | $7,943.28 | $8,128.31 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,456.54 / $9,772.37
| Professional | | $3,801.89 | $6,456.54 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.03 / $5,754.40 / $10,232.93
| Facility | | $6.03 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,754.40 / $7,413.10
| Professional | | $3,467.37 | $5,754.40 | $7,413.10 |