- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,942.80 / $1,942.80 / $1,942.80
| Facility | | $1,942.80 | $1,942.80 | $1,942.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.80 / $1,942.80 / $3,501.12
| Professional | | $1,942.80 | $1,942.80 | $3,501.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.60 / $4,975.75 / $23,010.90
| Facility | | $1,577.60 | $4,975.75 | $23,010.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.94 / $3,206.22 / $4,342.29
| Professional | | $2,002.94 | $3,206.22 | $4,342.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,693.85 / $5,738.15 / $7,361.40
| Facility | | $4,693.85 | $5,738.15 | $7,361.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,911.61 / $3,945.29 / $3,945.29
| Professional | | $2,911.61 | $3,945.29 | $3,945.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.60 / $3,268.13 / $3,364.97
| Facility | | $1,577.60 | $3,268.13 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $3,364.97 / $5,457.75
| Professional | | $2,456.42 | $3,364.97 | $5,457.75 |
- 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
- $3,600.14 / $3,600.14 / $3,780.15
| Professional | | $3,600.14 | $3,600.14 | $3,780.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,199.20 / $3,199.20 / $3,199.20
| Professional | | $3,199.20 | $3,199.20 | $3,199.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,556.83 / $23,010.90 / $23,010.90
| Facility | | $9,556.83 | $23,010.90 | $23,010.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.92 / $2,376.82 / $4,342.29
| Professional | | $1,736.92 | $2,376.82 | $4,342.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.39 / $2,376.82 / $4,256.76
| Professional | | $1,910.39 | $2,376.82 | $4,256.76 |