- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,911.96 / $1,911.96 / $1,911.96
| Facility | | $1,911.96 | $1,911.96 | $1,911.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.96 / $2,016.55 / $3,482.09
| Professional | | $1,911.96 | $2,016.55 | $3,482.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,850.46 / $8,990.35 / $20,912.72
| Facility | | $2,850.46 | $8,990.35 | $20,912.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,998.13 / $3,155.31 / $4,273.35
| Professional | | $1,998.13 | $3,155.31 | $4,273.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,644.58 / $5,650.66 / $7,276.99
| Facility | | $4,644.58 | $5,650.66 | $7,276.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,151.93 / $3,882.66 / $3,882.66
| Professional | | $3,151.93 | $3,882.66 | $3,882.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,502.67 / $2,528.88 / $3,067.76
| Facility | | $2,502.67 | $2,528.88 | $3,067.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.95 / $2,502.67 / $5,197.50
| Professional | | $1,826.95 | $2,502.67 | $5,197.50 |
- 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
- $3,542.98 / $3,542.98 / $3,720.13
| Professional | | $3,542.98 | $3,542.98 | $3,720.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,613.71 / $2,613.71 / $2,613.71
| Professional | | $2,613.71 | $2,613.71 | $2,613.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,101.40 / $20,912.72 / $20,912.72
| Facility | | $9,101.40 | $20,912.72 | $20,912.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.34 / $2,339.10 / $4,273.35
| Professional | | $1,709.34 | $2,339.10 | $4,273.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.70 / $2,346.78 / $4,273.35
| Professional | | $1,808.70 | $2,346.78 | $4,273.35 |