- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,171.58 / $2,171.58 / $2,171.58
| Facility | | $2,171.58 | $2,171.58 | $2,171.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.58 / $2,290.36 / $3,954.91
| Professional | | $2,171.58 | $2,290.36 | $3,954.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,446.79 / $13,273.67 / $23,712.81
| Facility | | $4,446.79 | $13,273.67 | $23,712.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.44 / $3,692.09 / $4,853.63
| Professional | | $2,269.44 | $3,692.09 | $4,853.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,426.80 / $6,417.96 / $8,265.12
| Facility | | $5,426.80 | $6,417.96 | $8,265.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,579.93 / $4,409.88 / $4,409.88
| Professional | | $3,579.93 | $4,409.88 | $4,409.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $3,294.10 / $5,903.25
| Professional | | $2,404.69 | $3,294.10 | $5,903.25 |
- 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
- $4,024.08 / $4,024.08 / $4,225.28
| Professional | | $4,024.08 | $4,024.08 | $4,225.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,628.40 / $3,628.40 / $3,628.40
| Professional | | $3,628.40 | $3,628.40 | $3,628.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,337.20 / $23,712.81 / $23,712.81
| Facility | | $10,337.20 | $23,712.81 | $23,712.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.45 / $2,656.72 / $4,853.63
| Professional | | $1,941.45 | $2,656.72 | $4,853.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.59 / $2,656.72 / $4,853.63
| Professional | | $2,158.59 | $2,656.72 | $4,853.63 |