- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,921.84 / $2,921.84 / $2,921.84
| Facility | | $2,921.84 | $2,921.84 | $2,921.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,921.84 / $2,921.84 / $5,234.91
| Professional | | $2,921.84 | $2,921.84 | $5,234.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.69 / $11,451.20 / $39,440.91
| Facility | | $3,630.69 | $11,451.20 | $39,440.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,106.84 / $4,821.95 / $6,530.53
| Professional | | $3,106.84 | $4,821.95 | $6,530.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,097.83 / $8,635.33 / $11,120.67
| Facility | | $7,097.83 | $8,635.33 | $11,120.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,378.89 / $5,933.46 / $5,933.46
| Professional | | $4,378.89 | $5,933.46 | $5,933.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,868.04 / $4,366.38 / $4,688.13
| Facility | | $3,868.04 | $4,366.38 | $4,688.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $4,366.38 / $7,825.13
| Professional | | $3,187.46 | $4,366.38 | $7,825.13 |
- 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
- $5,414.38 / $5,414.38 / $5,685.10
| Professional | | $5,414.38 | $5,414.38 | $5,685.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,956.53 / $3,956.53 / $3,956.53
| Professional | | $3,956.53 | $3,956.53 | $3,956.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,442.82 / $39,440.91 / $39,440.91
| Facility | | $14,442.82 | $39,440.91 | $39,440.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.21 / $3,574.60 / $6,530.53
| Professional | | $2,612.21 | $3,574.60 | $6,530.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.29 / $4,787.54 / $5,944.28
| Professional | | $3,012.29 | $4,787.54 | $5,944.28 |