- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $5,623.41
| Facility | | $2,691.53 | $3,548.13 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,265.80 / $13,803.84
| Professional | | $3,548.13 | $4,265.80 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $3,548.13 / $13,803.84
| Facility | | $56.23 | $3,548.13 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $28,840.32
| Professional | | $3,311.31 | $6,165.95 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,918.31 / $13,182.57
| Professional | | $3,890.45 | $6,918.31 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $5,888.44 / $8,912.51
| Facility | | $302.00 | $5,888.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,025.60 / $8,128.31
| Professional | | $4,786.30 | $6,025.60 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,311.31 / $5,888.44
| Facility | | $1,000.00 | $3,311.31 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,585.78 / $11,220.18
| Professional | | $4,265.80 | $7,585.78 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $3,548.13 / $13,803.84
| Facility | | $56.23 | $3,548.13 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $28,840.32
| Professional | | $3,311.31 | $5,888.44 | $28,840.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,311.31 / $4,677.35
| Facility | | $1,000.00 | $3,311.31 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $13,182.57
| Professional | | $4,265.80 | $6,309.57 | $13,182.57 |