- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,650.38 / $2,650.38 / $2,650.38
| Facility | | $2,650.38 | $2,650.38 | $2,650.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.38 / $2,839.76 / $5,319.86
| Professional | | $2,650.38 | $2,839.76 | $5,319.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,607.89 / $14,533.32 / $38,417.86
| Facility | | $4,607.89 | $14,533.32 | $38,417.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.91 / $4,663.35 / $5,923.81
| Professional | | $2,961.91 | $4,663.35 | $5,923.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,623.36 / $7,833.06 / $10,087.50
| Facility | | $6,623.36 | $7,833.06 | $10,087.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,972.05 / $5,382.20 / $5,382.20
| Professional | | $3,972.05 | $5,382.20 | $5,382.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $4,458.42
| Facility | | $3,790.37 | $3,790.37 | $4,458.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $3,790.37 / $7,784.25
| Professional | | $2,766.97 | $3,790.37 | $7,784.25 |
- 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
- $4,911.35 / $4,911.35 / $5,156.92
| Professional | | $4,911.35 | $4,911.35 | $5,156.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,211.37 / $4,211.37 / $4,211.37
| Professional | | $4,211.37 | $4,211.37 | $4,211.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,480.40 / $38,417.86 / $38,417.86
| Facility | | $16,480.40 | $38,417.86 | $38,417.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,507.23 / $3,299.41 / $5,923.81
| Professional | | $2,507.23 | $3,299.41 | $5,923.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.52 / $3,242.49 / $5,923.81
| Professional | | $2,634.52 | $3,242.49 | $5,923.81 |