- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,645.75 / $12,077.50 / $27,692.10
| Facility | | $3,645.75 | $12,077.50 | $27,692.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,443.42 / $3,645.75 / $3,762.10
| Professional | | $2,443.42 | $3,645.75 | $3,762.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.37 / $6,364.54 / $18,422.64
| Facility | | $4,072.37 | $6,364.54 | $18,422.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,490.61 / $10,957.77 / $29,088.38
| Professional | | $3,490.61 | $10,957.77 | $29,088.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,033.58 / $8,244.39 / $10,014.62
| Facility | | $4,033.58 | $8,244.39 | $10,014.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,490.60 / $3,878.45 / $6,593.36
| Facility | | $3,490.60 | $3,878.45 | $6,593.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,490.60 / $3,878.45 / $9,696.12
| Professional | | $3,490.60 | $3,878.45 | $9,696.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Professional | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.45 / $3,878.45 / $5,429.83
| Facility | | $3,878.45 | $3,878.45 | $5,429.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.45 / $6,787.29 / $11,635.35
| Facility | | $3,878.45 | $6,787.29 | $11,635.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,490.61 / $4,848.06 / $5,856.46
| Professional | | $3,490.61 | $4,848.06 | $5,856.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.37 / $6,399.44 / $10,665.74
| Facility | | $4,072.37 | $6,399.44 | $10,665.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,289.57 / $7,578.74 / $9,017.87
| Professional | | $4,289.57 | $7,578.74 | $9,017.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $1,628.95 / $4,343.85
| Professional | | $1,628.95 | $1,628.95 | $4,343.85 |