- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,814.78 / $1,814.78 / $1,814.78
| Facility | | $1,814.78 | $1,814.78 | $1,814.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.78 / $1,934.37 / $3,078.90
| Professional | | $1,814.78 | $1,934.37 | $3,078.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.30 / $8,755.12 / $24,984.00
| Facility | | $3,087.30 | $8,755.12 | $24,984.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.04 / $3,152.15 / $4,056.14
| Professional | | $1,968.04 | $3,152.15 | $4,056.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,535.14 / $5,363.45 / $6,907.11
| Facility | | $4,535.14 | $5,363.45 | $6,907.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,991.73 / $3,685.30 / $3,685.30
| Professional | | $2,991.73 | $3,685.30 | $3,685.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $3,052.79
| Facility | | $2,481.10 | $2,481.10 | $3,052.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $2,481.10 / $4,999.88
| Professional | | $1,811.20 | $2,481.10 | $4,999.88 |
- 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
- $3,362.89 / $3,362.89 / $3,531.03
| Professional | | $3,362.89 | $3,362.89 | $3,531.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,111.61 / $3,111.61 / $3,111.61
| Professional | | $3,111.61 | $3,111.61 | $3,111.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,755.12 / $24,984.00 / $24,984.00
| Facility | | $8,755.12 | $24,984.00 | $24,984.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.03 / $2,220.21 / $4,056.14
| Professional | | $1,640.03 | $2,220.21 | $4,056.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.14 / $2,600.65 / $2,965.23
| Facility | | $3.14 | $2,600.65 | $2,965.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.92 / $2,460.41 / $3,944.84
| Professional | | $1,803.92 | $2,460.41 | $3,944.84 |