- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,825.16 / $1,825.16 / $1,825.16
| Facility | | $1,825.16 | $1,825.16 | $1,825.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.16 / $1,825.16 / $3,261.30
| Professional | | $1,825.16 | $1,825.16 | $3,261.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.75 / $6,745.62 / $19,545.97
| Facility | | $2,138.75 | $6,745.62 | $19,545.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.62 / $2,930.32 / $4,079.38
| Professional | | $1,847.62 | $2,930.32 | $4,079.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,433.75 / $5,394.16 / $6,946.66
| Facility | | $4,433.75 | $5,394.16 | $6,946.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,735.32 / $3,706.40 / $3,706.40
| Professional | | $2,735.32 | $3,706.40 | $3,706.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.21 / $2,970.85 / $2,970.85
| Facility | | $2,416.21 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,970.85 / $4,887.38
| Professional | | $2,168.71 | $2,970.85 | $4,887.38 |
- 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
- $3,382.15 / $3,382.15 / $3,551.26
| Professional | | $3,382.15 | $3,382.15 | $3,551.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.14 / $2,473.14 / $2,473.14
| Professional | | $2,473.14 | $2,473.14 | $2,473.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,558.34 / $19,545.97 / $19,545.97
| Facility | | $8,558.34 | $19,545.97 | $19,545.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.75 / $2,232.91 / $4,079.38
| Professional | | $1,631.75 | $2,232.91 | $4,079.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.24 / $2,232.91 / $3,837.43
| Professional | | $1,814.24 | $2,232.91 | $3,837.43 |