- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.28 / $2,607.28 / $2,607.28
| Facility | | $2,607.28 | $2,607.28 | $2,607.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.84 / $2,607.28 / $3,954.86
| Professional | | $2,508.84 | $2,607.28 | $3,954.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,101.86 / $4,865.49 / $32,557.45
| Facility | | $3,101.86 | $4,865.49 | $32,557.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.12 / $4,009.68 / $4,633.80
| Professional | | $2,262.12 | $4,009.68 | $4,633.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $674.91 / $674.91 / $694.59
| Facility | | $674.91 | $674.91 | $694.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,370.59 / $5,251.12 / $5,251.12
| Professional | | $4,370.59 | $5,251.12 | $5,251.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $5,792.58
| Facility | | $1,642.21 | $1,642.21 | $5,792.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $1,642.21 / $8,648.44
| Professional | | $513.41 | $1,642.21 | $8,648.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.07 / $4,783.07 / $4,783.07
| Professional | | $4,783.07 | $4,783.07 | $4,783.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,101.86 / $3,101.86 / $3,101.86
| Professional | | $3,101.86 | $3,101.86 | $3,101.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $32,557.45 / $32,557.45
| Facility | | $100.00 | $32,557.45 | $32,557.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.11 / $2,951.64 / $5,012.10
| Professional | | $2,209.11 | $2,951.64 | $5,012.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.52 / $3,101.86 / $5,967.30
| Professional | | $2,260.52 | $3,101.86 | $5,967.30 |