- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,231.36 / $2,231.36 / $2,231.36
| Facility | | $2,231.36 | $2,231.36 | $2,231.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.36 / $2,231.36 / $3,486.07
| Professional | | $2,231.36 | $2,231.36 | $3,486.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,887.50 / $9,107.18 / $26,407.34
| Facility | | $2,887.50 | $9,107.18 | $26,407.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.63 / $3,384.15 / $4,987.25
| Professional | | $2,116.63 | $3,384.15 | $4,987.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,420.48 / $6,594.64 / $8,492.65
| Facility | | $5,420.48 | $6,594.64 | $8,492.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,344.06 / $4,531.28 / $4,531.28
| Professional | | $3,344.06 | $4,531.28 | $4,531.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.32 / $3,006.81 / $3,580.24
| Facility | | $2,951.32 | $3,006.81 | $3,580.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $3,006.81 / $5,388.75
| Professional | | $2,194.96 | $3,006.81 | $5,388.75 |
- 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
- $4,134.85 / $4,134.85 / $4,341.60
| Professional | | $4,134.85 | $4,134.85 | $4,341.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,649.07 / $2,649.07 / $2,649.07
| Professional | | $2,649.07 | $2,649.07 | $2,649.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,435.66 / $26,407.34 / $26,407.34
| Facility | | $9,435.66 | $26,407.34 | $26,407.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,994.90 / $2,729.85 / $4,987.25
| Professional | | $1,994.90 | $2,729.85 | $4,987.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.35 / $2,729.85 / $4,987.25
| Professional | | $1,944.35 | $2,729.85 | $4,987.25 |