- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.33 / $1,078.33 / $3,638.00
| Facility | | $1,078.33 | $1,078.33 | $3,638.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.33 / $1,078.33 / $1,492.22
| Professional | | $1,078.33 | $1,078.33 | $1,492.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,507.64 / $10,188.53 / $21,230.60
| Facility | | $4,507.64 | $10,188.53 | $21,230.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.35 / $2,646.08 / $3,712.77
| Professional | | $1,713.35 | $2,646.08 | $3,712.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,504.89 / $3,552.25 / $8,545.42
| Facility | | $2,504.89 | $3,552.25 | $8,545.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.56 / $3,424.81 / $4,871.60
| Professional | | $2,030.56 | $3,424.81 | $4,871.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,036.30 / $3,247.61 / $6,728.68
| Facility | | $2,036.30 | $3,247.61 | $6,728.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.72 / $3,059.32 / $4,054.26
| Professional | | $1,787.72 | $3,059.32 | $4,054.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.72 / $2,077.82 / $10,533.00
| Facility | | $1,287.72 | $2,077.82 | $10,533.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.26 / $2,556.55 / $5,497.45
| Professional | | $1,284.26 | $2,556.55 | $5,497.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.00 / $8,689.00 / $11,531.00
| Facility | | $3,940.00 | $8,689.00 | $11,531.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.87 / $2,556.55 / $4,239.32
| Professional | | $1,349.87 | $2,556.55 | $4,239.32 |