- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,132.57 / $2,132.57 / $2,132.57
| Facility | | $2,132.57 | $2,132.57 | $2,132.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.86 / $2,132.57 / $4,095.00
| Professional | | $1,596.86 | $2,132.57 | $4,095.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,290.42 / $3,826.83 / $25,593.57
| Facility | | $3,290.42 | $3,826.83 | $25,593.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.75 / $3,445.23 / $3,701.72
| Professional | | $1,808.75 | $3,445.23 | $3,701.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.83 / $508.83 / $523.66
| Facility | | $508.83 | $508.83 | $523.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,506.76 / $3,959.01 / $3,959.01
| Professional | | $3,506.76 | $3,959.01 | $3,959.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $4,460.29
| Facility | | $2,200.00 | $2,200.00 | $4,460.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.00 / $2,200.00 / $6,539.06
| Professional | | $1,870.00 | $2,200.00 | $6,539.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,606.01 / $3,606.01 / $3,606.01
| Professional | | $3,606.01 | $3,606.01 | $3,606.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,242.57 / $3,242.57 / $4,171.57
| Professional | | $3,242.57 | $3,242.57 | $4,171.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $25,593.57 / $25,593.57
| Facility | | $100.00 | $25,593.57 | $25,593.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.60 / $2,351.37 / $3,954.10
| Professional | | $1,740.60 | $2,351.37 | $3,954.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.60 / $2,405.39 / $4,696.70
| Professional | | $1,740.60 | $2,405.39 | $4,696.70 |