- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,054.11 / $2,054.11 / $2,054.11
| Facility | | $2,054.11 | $2,054.11 | $2,054.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.11 / $2,284.96 / $3,951.93
| Professional | | $2,054.11 | $2,284.96 | $3,951.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.87 / $6,768.07 / $29,550.18
| Facility | | $2,145.87 | $6,768.07 | $29,550.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.87 / $3,614.20 / $4,591.07
| Professional | | $2,145.87 | $3,614.20 | $4,591.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,989.89 / $6,070.78 / $7,818.01
| Facility | | $4,989.89 | $6,070.78 | $7,818.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,078.43 / $4,171.31 / $4,171.31
| Professional | | $3,078.43 | $4,171.31 | $4,171.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.30 / $3,455.38 / $3,798.08
| Facility | | $2,719.30 | $3,455.38 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $3,798.08 / $6,806.63
| Professional | | $2,772.60 | $3,798.08 | $6,806.63 |
- 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
- $3,806.40 / $3,806.40 / $3,996.72
| Professional | | $3,806.40 | $3,806.40 | $3,996.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,986.85 / $2,986.85 / $2,986.85
| Professional | | $2,986.85 | $2,986.85 | $2,986.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,918.72 / $29,550.18 / $29,550.18
| Facility | | $11,918.72 | $29,550.18 | $29,550.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.17 / $2,513.00 / $4,591.07
| Professional | | $1,943.17 | $2,513.00 | $4,591.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.81 / $2,643.46 / $4,591.07
| Professional | | $2,041.81 | $2,643.46 | $4,591.07 |