- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $4,168.69
| Professional | | $2,187.76 | $2,754.23 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $28,840.32
| Facility | | $3,548.13 | $4,365.16 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,548.13 / $4,365.16
| Professional | | $1,949.84 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $630.96
| Facility | | $616.60 | $616.60 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $4,677.35
| Professional | | $3,715.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $5,248.07
| Facility | | $3,235.94 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $3,235.94 / $7,585.78
| Professional | | $457.09 | $3,235.94 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,570.88 / $4,570.88
| Professional | | $1,995.26 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $28,840.32
| Facility | | $3,548.13 | $4,365.16 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,548.13 / $4,570.88
| Professional | | $1,995.26 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.02 / $1,659.59 / $3,548.13
| Facility | | $3.02 | $1,659.59 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,548.13 / $5,370.32
| Professional | | $1,949.84 | $3,548.13 | $5,370.32 |