- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.33 / $2,416.33 / $2,416.33
| Facility | | $2,416.33 | $2,416.33 | $2,416.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.33 / $2,416.33 / $3,504.29
| Professional | | $2,416.33 | $2,416.33 | $3,504.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,949.30 / $9,302.09 / $25,314.56
| Facility | | $2,949.30 | $9,302.09 | $25,314.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.41 / $3,547.42 / $5,400.68
| Professional | | $2,266.41 | $3,547.42 | $5,400.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,837.93 / $7,136.76 / $9,155.66
| Facility | | $5,837.93 | $7,136.76 | $9,155.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,621.28 / $4,906.89 / $4,906.89
| Professional | | $3,621.28 | $4,906.89 | $4,906.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,198.83 / $3,523.90 / $3,877.03
| Facility | | $3,198.83 | $3,523.90 | $3,877.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.44 / $3,523.90 / $6,315.38
| Professional | | $2,572.44 | $3,523.90 | $6,315.38 |
- 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
- $4,477.63 / $4,477.63 / $4,701.51
| Professional | | $4,477.63 | $4,477.63 | $4,701.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.88 / $2,776.88 / $2,776.88
| Professional | | $2,776.88 | $2,776.88 | $2,776.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,058.28 / $25,314.56 / $25,314.56
| Facility | | $11,058.28 | $25,314.56 | $25,314.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.27 / $2,956.14 / $5,400.68
| Professional | | $2,160.27 | $2,956.14 | $5,400.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.52 / $2,956.14 / $4,914.00
| Professional | | $2,180.52 | $2,956.14 | $4,914.00 |