- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.44 / $4,265.22 / $4,265.22
| Facility | | $3,745.44 | $4,265.22 | $4,265.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.77 / $2,732.14 / $4,303.76
| Professional | | $2,132.77 | $2,732.14 | $4,303.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $5,573.94
| Facility | | $3,294.10 | $3,294.10 | $5,573.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,294.10 / $5,903.25 / $7,379.06
| Professional | | $3,294.10 | $5,903.25 | $7,379.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,837.60 / $5,092.22 / $6,022.72
| Professional | | $4,837.60 | $5,092.22 | $6,022.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,231.45 / $6,587.39 / $23,712.81
| Facility | | $3,231.45 | $6,587.39 | $23,712.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,422.46 / $3,170.22 / $6,923.29
| Professional | | $2,422.46 | $3,170.22 | $6,923.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,557.64 / $5,573.94 / $6,910.61
| Facility | | $5,557.64 | $5,573.94 | $6,910.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,565.09 / $6,511.13 / $10,651.68
| Professional | | $4,565.09 | $6,511.13 | $10,651.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,415.28 / $2,612.25 / $5,962.23
| Professional | | $2,415.28 | $2,612.25 | $5,962.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,965.88 / $4,965.88 / $4,965.88
| Facility | | $4,965.88 | $4,965.88 | $4,965.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,923.05 / $4,965.88 / $4,965.88
| Professional | | $3,923.05 | $4,965.88 | $4,965.88 |