- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,915.21 / $2,915.21 / $2,915.21
| Facility | | $2,915.21 | $2,915.21 | $2,915.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.21 / $2,915.21 / $4,182.71
| Professional | | $2,915.21 | $2,915.21 | $4,182.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,565.60 / $11,245.90 / $33,270.94
| Facility | | $3,565.60 | $11,245.90 | $33,270.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,724.04 / $4,263.72 / $6,515.71
| Professional | | $2,724.04 | $4,263.72 | $6,515.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,285.15 / $8,615.73 / $11,095.43
| Facility | | $7,285.15 | $8,615.73 | $11,095.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,368.93 / $5,920.00 / $5,920.00
| Professional | | $4,368.93 | $5,920.00 | $5,920.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,855.83 / $3,943.38 / $4,677.47
| Facility | | $3,855.83 | $3,943.38 | $4,677.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $3,943.38 / $7,066.88
| Professional | | $2,878.67 | $3,943.38 | $7,066.88 |
- 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
- $5,402.08 / $5,402.08 / $5,672.18
| Professional | | $5,402.08 | $5,402.08 | $5,672.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,337.59 / $3,337.59 / $3,337.59
| Professional | | $3,337.59 | $3,337.59 | $3,337.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,374.74 / $33,270.94 / $33,270.94
| Facility | | $12,374.74 | $33,270.94 | $33,270.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.28 / $3,566.48 / $6,515.71
| Professional | | $2,606.28 | $3,566.48 | $6,515.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,620.82 / $3,566.48 / $5,594.18
| Professional | | $2,620.82 | $3,566.48 | $5,594.18 |