- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,209.13 / $2,209.13 / $2,209.13
| Facility | | $2,209.13 | $2,209.13 | $2,209.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.13 / $2,209.13 / $3,853.72
| Professional | | $2,209.13 | $2,209.13 | $3,853.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.89 / $6,960.53 / $29,034.76
| Facility | | $2,206.89 | $6,960.53 | $29,034.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.80 / $3,627.36 / $4,937.55
| Professional | | $2,279.80 | $3,627.36 | $4,937.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,366.48 / $6,528.94 / $8,408.04
| Facility | | $5,366.48 | $6,528.94 | $8,408.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,310.74 / $4,486.12 / $4,486.12
| Professional | | $3,310.74 | $4,486.12 | $4,486.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,924.50 / $3,670.30 / $3,670.30
| Facility | | $2,924.50 | $3,670.30 | $3,670.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $3,670.30 / $6,577.50
| Professional | | $2,679.32 | $3,670.30 | $6,577.50 |
- 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
- $4,093.67 / $4,093.67 / $4,298.35
| Professional | | $4,093.67 | $4,093.67 | $4,298.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,912.63 / $2,912.63 / $2,912.63
| Professional | | $2,912.63 | $2,912.63 | $2,912.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,517.75 / $29,034.76 / $29,034.76
| Facility | | $11,517.75 | $29,034.76 | $29,034.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.02 / $2,702.65 / $4,937.55
| Professional | | $1,975.02 | $2,702.65 | $4,937.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.90 / $2,702.65 / $4,584.43
| Professional | | $2,195.90 | $2,702.65 | $4,584.43 |