- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $6,025.60
| Professional | | $1,995.26 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,011.87 / $28,840.32
| Facility | | $4,365.16 | $5,011.87 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,715.35 / $5,011.87
| Professional | | $2,290.87 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,456.54 / $8,511.38
| Facility | | $5,248.07 | $6,456.54 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $4,365.16
| Professional | | $3,235.94 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $3,548.13
| Facility | | $2,818.38 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,548.13
| Professional | | $2,570.40 | $2,570.40 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $6,606.93
| Professional | | $4,265.80 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,011.87 / $28,840.32
| Facility | | $4,365.16 | $5,011.87 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,715.35 / $5,495.41
| Professional | | $2,290.87 | $3,715.35 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.63 / $3,467.37 / $6,165.95
| Facility | | $3.63 | $3,467.37 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $4,265.80
| Professional | | $2,137.96 | $3,388.44 | $4,265.80 |