- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,012.25 / $3,012.25 / $3,012.25
| Facility | | $3,012.25 | $3,012.25 | $3,012.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.86 / $2,359.60 / $3,012.25
| Professional | | $1,932.86 | $2,359.60 | $3,012.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.00 / $313.12 / $10,386.02
| Professional | | $304.00 | $313.12 | $10,386.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,819.42 / $3,819.42 / $3,819.42
| Facility | | $3,819.42 | $3,819.42 | $3,819.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.99 / $8,072.53 / $12,383.46
| Facility | | $6,907.99 | $8,072.53 | $12,383.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,697.57 / $6,759.49 / $7,681.24
| Professional | | $2,697.57 | $6,759.49 | $7,681.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.86 / $3,012.25 / $8,785.74
| Facility | | $1,932.86 | $3,012.25 | $8,785.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.86 / $3,012.25 / $8,785.74
| Facility | | $1,932.86 | $3,012.25 | $8,785.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.10 / $1,506.13 / $7,741.11
| Professional | | $1,255.10 | $1,506.13 | $7,741.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $70.00 / $85.00
| Professional | | $50.00 | $70.00 | $85.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.86 / $3,012.25 / $8,785.74
| Facility | | $1,932.86 | $3,012.25 | $8,785.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,190.39 / $5,985.29 / $8,394.77
| Professional | | $4,190.39 | $5,985.29 | $8,394.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,020.42 / $11,923.50 / $11,923.50
| Facility | | $5,020.42 | $11,923.50 | $11,923.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,040.84 / $10,040.84 / $12,500.85
| Professional | | $10,040.84 | $10,040.84 | $12,500.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,345.60 / $5,345.60 / $5,345.60
| Professional | | $5,345.60 | $5,345.60 | $5,345.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,705.75 / $13,705.75 / $13,705.75
| Professional | | $13,705.75 | $13,705.75 | $13,705.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.10 / $1,506.13 / $5,271.44
| Professional | | $1,255.10 | $1,506.13 | $5,271.44 |