- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,066.66 / $3,066.66 / $3,066.66
| Facility | | $3,066.66 | $3,066.66 | $3,066.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,066.66 / $3,066.66 / $4,203.78
| Professional | | $3,066.66 | $3,066.66 | $4,203.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,862.50 / $12,182.33 / $33,799.96
| Facility | | $3,862.50 | $12,182.33 | $33,799.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.71 / $4,331.51 / $6,854.20
| Professional | | $2,759.71 | $4,331.51 | $6,854.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,449.62 / $9,063.32 / $11,671.85
| Facility | | $7,449.62 | $9,063.32 | $11,671.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,595.89 / $6,227.54 / $6,227.54
| Professional | | $4,595.89 | $6,227.54 | $6,227.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,059.73 / $4,072.36 / $4,920.46
| Facility | | $4,059.73 | $4,072.36 | $4,920.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $4,072.36 / $7,298.25
| Professional | | $2,972.82 | $4,072.36 | $7,298.25 |
- 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
- $5,682.72 / $5,682.72 / $5,966.86
| Professional | | $5,682.72 | $5,682.72 | $5,966.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,481.21 / $3,481.21 / $3,481.21
| Professional | | $3,481.21 | $3,481.21 | $3,481.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,838.84 / $33,799.96 / $33,799.96
| Facility | | $12,838.84 | $33,799.96 | $33,799.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.49 / $3,751.75 / $6,854.20
| Professional | | $2,662.49 | $3,751.75 | $6,854.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.20 / $3,751.75 / $5,902.08
| Professional | | $2,672.20 | $3,751.75 | $5,902.08 |