- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $4,897.79
| Professional | | $2,630.27 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $5,248.07 / $34,673.69
| Facility | | $93.33 | $5,248.07 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,168.69 / $5,248.07
| Professional | | $2,344.23 | $4,168.69 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $758.58
| Facility | | $741.31 | $741.31 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,623.41 / $5,623.41
| Professional | | $4,677.35 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,168.69
| Facility | | $3,467.37 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $3,467.37 / $7,413.10
| Professional | | $549.54 | $3,467.37 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,495.41 / $5,495.41
| Professional | | $2,398.83 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Professional | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $5,248.07 / $34,673.69
| Facility | | $93.33 | $5,248.07 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,265.80 / $5,495.41
| Professional | | $2,344.23 | $4,265.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.63 / $1,995.26 / $4,265.80
| Facility | | $3.63 | $1,995.26 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,168.69 / $6,456.54
| Professional | | $2,344.23 | $4,168.69 | $6,456.54 |