- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $3,311.31
| Professional | | $1,862.09 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,365.16 / $8,709.64
| Facility | | $3,630.78 | $4,365.16 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,388.44 / $3,388.44
| Professional | | $3,311.31 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $2,754.23
| Facility | | $1,949.84 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $3,467.37
| Professional | | $1,995.26 | $1,995.26 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,691.53
| Professional | | $2,137.96 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,630.78 / $6,025.60
| Facility | | $1,819.70 | $3,630.78 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,951.21 / $3,548.13
| Facility | | $1,659.59 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $3,090.30
| Professional | | $1,698.24 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $22,908.68 / $22,908.68
| Facility | | $22,908.68 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $29,512.09
| Professional | | $23,988.33 | $23,988.33 | $29,512.09 |