- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,389.30 / $2,389.30 / $2,389.30
| Facility | | $2,389.30 | $2,389.30 | $2,389.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.30 / $2,389.30 / $4,392.10
| Professional | | $2,389.30 | $2,389.30 | $4,392.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,892.64 / $14,604.53 / $33,025.99
| Facility | | $4,892.64 | $14,604.53 | $33,025.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.52 / $4,150.08 / $5,340.27
| Professional | | $2,601.52 | $4,150.08 | $5,340.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,804.17 / $7,061.43 / $9,093.79
| Facility | | $5,804.17 | $7,061.43 | $9,093.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,580.76 / $4,596.64 / $4,596.64
| Professional | | $3,580.76 | $4,596.64 | $4,596.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,163.05 / $3,745.37 / $3,833.66
| Facility | | $3,163.05 | $3,745.37 | $3,833.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $6,712.13
| Professional | | $2,734.12 | $2,734.12 | $6,712.13 |
- 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
- $4,427.55 / $4,427.55 / $4,648.93
| Professional | | $4,427.55 | $4,427.55 | $4,648.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,935.02 / $3,935.02 / $3,935.02
| Professional | | $3,935.02 | $3,935.02 | $3,935.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,753.31 / $33,025.99 / $33,025.99
| Facility | | $11,753.31 | $33,025.99 | $33,025.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.94 / $2,923.07 / $5,340.27
| Professional | | $2,167.94 | $2,923.07 | $5,340.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.00 / $3,055.45 / $5,235.09
| Professional | | $2,375.00 | $3,055.45 | $5,235.09 |