- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,883.80 / $1,883.80 / $1,883.80
| Facility | | $1,883.80 | $1,883.80 | $1,883.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.80 / $1,885.54 / $3,543.06
| Professional | | $1,883.80 | $1,885.54 | $3,543.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,273.00 / $7,169.04 / $26,694.24
| Facility | | $2,273.00 | $7,169.04 | $26,694.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.75 / $3,240.28 / $4,210.43
| Professional | | $2,102.75 | $3,240.28 | $4,210.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,576.18 / $5,567.46 / $7,169.83
| Facility | | $4,576.18 | $5,567.46 | $7,169.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.19 / $3,825.48 / $3,825.48
| Professional | | $2,823.19 | $3,825.48 | $3,825.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,493.84 / $3,168.89 / $3,249.00
| Facility | | $2,493.84 | $3,168.89 | $3,249.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.77 / $3,249.00 / $5,990.63
| Professional | | $2,371.77 | $3,249.00 | $5,990.63 |
- 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
- $3,490.81 / $3,490.81 / $3,665.35
| Professional | | $3,490.81 | $3,490.81 | $3,665.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,677.85 / $2,677.85 / $2,677.85
| Professional | | $2,677.85 | $2,677.85 | $2,677.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,490.21 / $26,694.24 / $26,694.24
| Facility | | $10,490.21 | $26,694.24 | $26,694.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.30 / $2,403.73 / $4,210.43
| Professional | | $1,752.30 | $2,403.73 | $4,210.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.06 / $2,304.65 / $4,210.43
| Professional | | $1,782.06 | $2,304.65 | $4,210.43 |