- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,603.46 / $2,603.46 / $2,603.46
| Facility | | $2,603.46 | $2,603.46 | $2,603.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.46 / $2,603.46 / $3,758.92
| Professional | | $2,603.46 | $2,603.46 | $3,758.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,559.50 / $10,877.82 / $28,320.45
| Facility | | $3,559.50 | $10,877.82 | $28,320.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,462.85 / $3,737.48 / $5,818.92
| Professional | | $2,462.85 | $3,737.48 | $5,818.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,324.40 / $7,694.36 / $9,908.87
| Facility | | $6,324.40 | $7,694.36 | $9,908.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,901.73 / $5,286.91 / $5,286.91
| Professional | | $3,901.73 | $5,286.91 | $5,286.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,446.55 / $3,813.78 / $4,177.28
| Facility | | $3,446.55 | $3,813.78 | $4,177.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $3,813.78 / $6,212.25
| Professional | | $2,784.06 | $3,813.78 | $6,212.25 |
- 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
- $4,824.39 / $4,824.39 / $5,065.60
| Professional | | $4,824.39 | $4,824.39 | $5,065.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,840.97 / $2,840.97 / $2,840.97
| Professional | | $2,840.97 | $2,840.97 | $2,840.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,877.82 / $28,320.45 / $28,320.45
| Facility | | $10,877.82 | $28,320.45 | $28,320.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $3,185.09 / $5,818.92
| Professional | | $2,230.86 | $3,185.09 | $5,818.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $3,185.09 / $5,427.48
| Professional | | $2,230.86 | $3,185.09 | $5,427.48 |