- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,009.06 / $2,009.06 / $2,009.06
| Facility | | $2,009.06 | $2,009.06 | $2,009.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.73 / $2,005.57 / $2,009.06
| Professional | | $1,045.73 | $2,005.57 | $2,009.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,054.71 / $2,398.60 / $3,339.96
| Facility | | $2,054.71 | $2,398.60 | $3,339.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.88 / $2,278.67 / $2,398.60
| Professional | | $1,918.88 | $2,278.67 | $2,398.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $7,401.17 / $20,556.12
| Facility | | $1,654.54 | $7,401.17 | $20,556.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.63 / $2,947.46 / $3,531.39
| Professional | | $2,780.63 | $2,947.46 | $3,531.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,393.99 / $7,101.06 / $16,185.93
| Facility | | $4,393.99 | $7,101.06 | $16,185.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.63 / $2,780.63 / $2,861.60
| Professional | | $2,780.63 | $2,780.63 | $2,861.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.53 / $2,398.60 / $12,123.54
| Facility | | $755.53 | $2,398.60 | $12,123.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.48 / $1,196.63 / $2,450.05
| Professional | | $757.48 | $1,196.63 | $2,450.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.65 / $1,893.70 / $4,733.22
| Professional | | $889.65 | $1,893.70 | $4,733.22 |