- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,394.14 / $2,160.54 / $10,561.00
| Facility | | $1,394.14 | $2,160.54 | $10,561.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.14 / $1,394.14 / $2,301.08
| Professional | | $1,394.14 | $1,394.14 | $2,301.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.38 / $2,951.33 / $3,620.59
| Professional | | $1,836.38 | $2,951.33 | $3,620.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.04 / $2,383.98 / $3,786.31
| Professional | | $1,669.04 | $2,383.98 | $3,786.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,394.14 / $1,883.76 / $3,495.44
| Facility | | $1,394.14 | $1,883.76 | $3,495.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.76 / $1,883.76 / $3,491.14
| Professional | | $1,883.76 | $1,883.76 | $3,491.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $2,110.40 / $3,701.00
| Professional | | $6.00 | $2,110.40 | $3,701.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,366.00 / $9,541.00 / $14,589.00
| Facility | | $3,366.00 | $9,541.00 | $14,589.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.33 / $1,928.26 / $3,823.48
| Professional | | $1,377.33 | $1,928.26 | $3,823.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $9,062.12 / $13,960.05
| Facility | | $2,000.00 | $9,062.12 | $13,960.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,165.76 / $10,165.76 / $11,841.08
| Professional | | $10,165.76 | $10,165.76 | $11,841.08 |