- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,528.10 / $1,528.10 / $1,528.10
| Facility | | $1,528.10 | $1,528.10 | $1,528.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.10 / $1,538.41 / $2,890.79
| Professional | | $1,528.10 | $1,538.41 | $2,890.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,129.15 / $9,340.51 / $20,817.16
| Facility | | $3,129.15 | $9,340.51 | $20,817.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.81 / $2,654.23 / $3,415.43
| Professional | | $1,639.81 | $2,654.23 | $3,415.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,712.12 / $4,516.22 / $5,816.04
| Facility | | $3,712.12 | $4,516.22 | $5,816.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,519.13 / $2,939.84 / $2,939.84
| Professional | | $2,519.13 | $2,939.84 | $2,939.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,022.95 / $2,400.00 / $2,451.86
| Facility | | $2,022.95 | $2,400.00 | $2,451.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.00 / $2,400.00 / $4,293.00
| Professional | | $1,752.00 | $2,400.00 | $4,293.00 |
- 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
- $2,831.69 / $2,831.69 / $2,973.27
| Professional | | $2,831.69 | $2,831.69 | $2,973.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.60 / $2,516.69 / $2,516.69
| Professional | | $2,040.60 | $2,516.69 | $2,516.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,516.95 / $20,817.16 / $20,817.16
| Facility | | $7,516.95 | $20,817.16 | $20,817.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.51 / $1,869.49 / $3,415.43
| Professional | | $1,366.51 | $1,869.49 | $3,415.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.96 / $1,869.49 / $3,348.14
| Professional | | $1,518.96 | $1,869.49 | $3,348.14 |