- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.10 / $1,743.10 / $1,743.10
| Facility | | $1,743.10 | $1,743.10 | $1,743.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.10 / $1,743.10 / $2,752.45
| Professional | | $1,743.10 | $1,743.10 | $2,752.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,237.40 / $7,056.76 / $20,737.59
| Facility | | $2,237.40 | $7,056.76 | $20,737.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.18 / $2,657.56 / $3,895.95
| Professional | | $1,662.18 | $2,657.56 | $3,895.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,234.39 / $5,151.62 / $6,634.32
| Facility | | $4,234.39 | $5,151.62 | $6,634.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.32 / $3,539.75 / $3,539.75
| Professional | | $2,612.32 | $3,539.75 | $3,539.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,307.57 / $2,694.60 / $2,796.81
| Facility | | $2,307.57 | $2,694.60 | $2,796.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $4,578.00
| Professional | | $1,967.06 | $1,967.06 | $4,578.00 |
- 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
- $3,230.08 / $3,230.08 / $3,391.58
| Professional | | $3,230.08 | $3,230.08 | $3,391.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.31 / $2,080.31 / $2,080.31
| Professional | | $2,080.31 | $2,080.31 | $2,080.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,016.27 / $20,737.59 / $20,737.59
| Facility | | $8,016.27 | $20,737.59 | $20,737.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.38 / $2,132.50 / $3,895.95
| Professional | | $1,558.38 | $2,132.50 | $3,895.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.54 / $2,132.50 / $3,546.21
| Professional | | $1,633.54 | $2,132.50 | $3,546.21 |