- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.21 / $2,262.21 / $2,262.21
| Facility | | $2,262.21 | $2,262.21 | $2,262.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.58 / $1,990.66 / $2,262.21
| Professional | | $1,210.58 | $1,990.66 | $2,262.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,313.64 / $2,700.85 / $3,760.85
| Facility | | $2,313.64 | $2,700.85 | $3,760.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.67 / $2,565.81 / $2,700.85
| Professional | | $2,160.67 | $2,565.81 | $2,700.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $8,333.29 / $23,145.04
| Facility | | $1,747.16 | $8,333.29 | $23,145.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.25 / $3,319.13 / $3,976.69
| Professional | | $3,131.25 | $3,319.13 | $3,976.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,947.38 / $7,995.39 / $18,224.43
| Facility | | $4,947.38 | $7,995.39 | $18,224.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.25 / $3,131.25 / $3,222.00
| Professional | | $3,131.25 | $3,131.25 | $3,222.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $749.91 / $2,700.85 / $11,750.92
| Facility | | $749.91 | $2,700.85 | $11,750.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.85 / $1,261.73 / $2,712.14
| Professional | | $751.85 | $1,261.73 | $2,712.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.85 / $1,261.73 / $3,565.12
| Professional | | $751.85 | $1,261.73 | $3,565.12 |