- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,105.48 / $2,105.48 / $2,105.48
| Facility | | $2,105.48 | $2,105.48 | $2,105.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,105.48 / $2,279.23 / $3,086.29
| Professional | | $2,105.48 | $2,279.23 | $3,086.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,311.43 / $13,727.08 / $22,996.26
| Facility | | $4,311.43 | $13,727.08 | $22,996.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.76 / $3,580.59 / $4,705.89
| Professional | | $1,991.76 | $3,580.59 | $4,705.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,261.63 / $6,222.62 / $8,013.56
| Facility | | $5,261.63 | $6,222.62 | $8,013.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,049.09 / $3,714.93 / $3,714.93
| Professional | | $3,049.09 | $3,714.93 | $3,714.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $5,723.63
| Professional | | $2,012.35 | $2,012.35 | $5,723.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,901.60 / $3,901.60 / $4,096.68
| Professional | | $3,901.60 | $3,901.60 | $4,096.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.35 / $3,090.35 / $3,090.35
| Professional | | $3,090.35 | $3,090.35 | $3,090.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,022.50 / $22,996.26 / $22,996.26
| Facility | | $10,022.50 | $22,996.26 | $22,996.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.10 / $2,404.07 / $4,705.89
| Professional | | $1,834.10 | $2,404.07 | $4,705.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.35 / $2,404.07 / $4,705.89
| Professional | | $1,865.35 | $2,404.07 | $4,705.89 |