- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,599.76 / $4,599.76 / $4,599.76
| Facility | | $4,599.76 | $4,599.76 | $4,599.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,426.04 / $4,599.76 / $7,888.23
| Professional | | $4,426.04 | $4,599.76 | $7,888.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,993.64 / $8,348.45 / $56,543.95
| Facility | | $6,993.64 | $8,348.45 | $56,543.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,901.14 / $7,343.32 / $7,981.54
| Professional | | $3,901.14 | $7,343.32 | $7,981.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.18 / $1,124.18 / $1,156.96
| Facility | | $1,124.18 | $1,124.18 | $1,156.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,453.47 / $8,746.70 / $8,746.70
| Professional | | $7,453.47 | $8,746.70 | $8,746.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $9,791.93
| Facility | | $4,933.43 | $4,933.43 | $9,791.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.42 / $4,933.43 / $14,446.88
| Professional | | $4,193.42 | $4,933.43 | $14,446.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,966.87 / $7,966.87 / $7,966.87
| Professional | | $7,966.87 | $7,966.87 | $7,966.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,993.36 / $6,993.36 / $9,158.08
| Professional | | $6,993.36 | $6,993.36 | $9,158.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $56,543.95 / $56,543.95
| Facility | | $100.00 | $56,543.95 | $56,543.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,821.24 / $5,071.47 / $8,618.29
| Professional | | $3,821.24 | $5,071.47 | $8,618.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.92 / $4,309.14 / $6,668.40
| Facility | | $430.92 | $4,309.14 | $6,668.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,897.24 / $5,188.00 / $10,248.60
| Professional | | $3,897.24 | $5,188.00 | $10,248.60 |