- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.42 / $2,117.42 / $2,117.42
| Facility | | $2,117.42 | $2,117.42 | $2,117.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.34 / $2,117.42 / $3,076.85
| Professional | | $2,096.34 | $2,117.42 | $3,076.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,589.30 / $8,166.65 / $21,500.64
| Facility | | $2,589.30 | $8,166.65 | $21,500.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.83 / $3,003.38 / $4,732.60
| Professional | | $1,918.83 | $3,003.38 | $4,732.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,143.72 / $6,257.94 / $8,059.04
| Facility | | $5,143.72 | $6,257.94 | $8,059.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,173.33 / $4,299.92 / $4,299.92
| Professional | | $3,173.33 | $4,299.92 | $4,299.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,803.13 / $3,397.44
| Facility | | $2,717.61 | $2,803.13 | $3,397.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $4,977.38
| Professional | | $1,983.86 | $2,717.61 | $4,977.38 |
- 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
- $3,923.74 / $3,923.74 / $4,119.93
| Professional | | $3,923.74 | $3,923.74 | $4,119.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,363.90 / $2,363.90 / $2,363.90
| Professional | | $2,363.90 | $2,363.90 | $2,363.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,715.37 / $21,500.64 / $21,500.64
| Facility | | $8,715.37 | $21,500.64 | $21,500.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.11 / $2,590.46 / $4,732.60
| Professional | | $1,846.11 | $2,590.46 | $4,732.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.48 / $2,590.46 / $3,923.74
| Professional | | $1,878.48 | $2,590.46 | $3,923.74 |