- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,059.67 / $3,175.86 / $17,227.09
| Facility | | $3,059.67 | $3,175.86 | $17,227.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,098.40 / $3,873.00
| Professional | | $2,711.10 | $3,098.40 | $3,873.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,410.94 / $3,485.70 / $4,070.52
| Facility | | $2,410.94 | $3,485.70 | $4,070.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.00 / $846.27 / $846.27
| Professional | | $680.00 | $846.27 | $846.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,647.60 / $40,666.50 / $97,599.60
| Facility | | $4,647.60 | $40,666.50 | $97,599.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,453.95 / $5,422.20 / $106,989.44
| Professional | | $4,453.95 | $5,422.20 | $106,989.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,517.44 / $3,013.58 / $5,110.42
| Facility | | $2,517.44 | $3,013.58 | $5,110.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,494.99 / $18,667.86 / $18,667.86
| Professional | | $4,494.99 | $18,667.86 | $18,667.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $3,873.00
| Professional | | $1,626.66 | $2,323.80 | $3,873.00 |