- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,964.61 / $2,964.61 / $2,964.61
| Facility | | $2,964.61 | $2,964.61 | $2,964.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.81 / $2,680.93 / $2,964.61
| Professional | | $1,324.81 | $2,680.93 | $2,964.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,031.98 / $3,539.42 / $4,928.54
| Facility | | $3,031.98 | $3,539.42 | $4,928.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.54 / $3,362.45 / $3,539.42
| Professional | | $2,831.54 | $3,362.45 | $3,539.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.62 / $10,920.71 / $30,331.35
| Facility | | $2,289.62 | $10,920.71 | $30,331.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,103.25 / $4,349.45 / $5,211.13
| Professional | | $4,103.25 | $4,349.45 | $5,211.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,483.50 / $10,477.89 / $23,882.95
| Facility | | $6,483.50 | $10,477.89 | $23,882.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,103.25 / $4,103.25 / $4,222.39
| Professional | | $4,103.25 | $4,103.25 | $4,222.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.16 / $3,539.42 / $15,617.77
| Facility | | $957.16 | $3,539.42 | $15,617.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.63 / $1,610.43 / $3,554.21
| Professional | | $959.63 | $1,610.43 | $3,554.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.07 / $1,906.45 / $5,996.41
| Professional | | $1,127.07 | $1,906.45 | $5,996.41 |