- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,593.44 / $2,593.44 / $2,593.44
| Facility | | $2,593.44 | $2,593.44 | $2,593.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,593.44 / $2,593.44 / $3,771.92
| Professional | | $2,593.44 | $2,593.44 | $3,771.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,400.00 / $10,723.60 / $30,607.53
| Facility | | $3,400.00 | $10,723.60 | $30,607.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.37 / $3,922.41 / $5,796.54
| Professional | | $2,453.37 | $3,922.41 | $5,796.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,300.08 / $7,664.78 / $9,870.78
| Facility | | $6,300.08 | $7,664.78 | $9,870.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,886.71 / $5,266.58 / $5,266.58
| Professional | | $3,886.71 | $5,266.58 | $5,266.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,433.29 / $3,578.08 / $4,161.20
| Facility | | $3,433.29 | $3,578.08 | $4,161.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $6,412.50
| Professional | | $2,612.00 | $2,612.00 | $6,412.50 |
- 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
- $4,805.84 / $4,805.84 / $5,046.13
| Professional | | $4,805.84 | $4,805.84 | $5,046.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,238.46 / $3,238.46 / $3,238.46
| Professional | | $3,238.46 | $3,238.46 | $3,238.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,269.36 / $30,607.53 / $30,607.53
| Facility | | $14,269.36 | $30,607.53 | $30,607.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.62 / $3,172.82 / $5,796.54
| Professional | | $2,318.62 | $3,172.82 | $5,796.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,577.92 / $3,823.86 / $5,335.11
| Professional | | $2,577.92 | $3,823.86 | $5,335.11 |