- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,310.61 / $2,310.61 / $2,310.61
| Facility | | $2,310.61 | $2,310.61 | $2,310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.29 / $2,310.61 / $2,772.73
| Professional | | $2,223.29 | $2,310.61 | $2,772.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,513.04 / $4,302.89 / $28,730.61
| Facility | | $3,513.04 | $4,302.89 | $28,730.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.65 / $3,688.69 / $4,098.00
| Professional | | $2,004.65 | $3,688.69 | $4,098.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $595.58 / $595.58 / $612.95
| Facility | | $595.58 | $595.58 | $612.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,744.02 / $4,633.92 / $4,633.92
| Professional | | $3,744.02 | $4,633.92 | $4,633.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $5,117.10
| Facility | | $3,248.38 | $3,248.38 | $5,117.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.13 / $3,248.38 / $7,654.69
| Professional | | $453.13 | $3,248.38 | $7,654.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,220.72 / $4,220.72 / $4,220.72
| Professional | | $4,220.72 | $4,220.72 | $4,220.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,513.04 / $3,513.04 / $3,513.04
| Professional | | $3,513.04 | $3,513.04 | $3,513.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $28,730.61 / $28,730.61
| Facility | | $100.00 | $28,730.61 | $28,730.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.66 / $2,610.23 / $4,433.20
| Professional | | $1,957.66 | $2,610.23 | $4,433.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.62 / $2,854.35 / $5,128.00
| Professional | | $1,959.62 | $2,854.35 | $5,128.00 |