- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.97 / $1,615.97 / $1,615.97
| Facility | | $1,615.97 | $1,615.97 | $1,615.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.97 / $1,615.97 / $2,514.87
| Professional | | $1,615.97 | $1,615.97 | $2,514.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.30 / $6,094.47 / $16,380.05
| Facility | | $1,932.30 | $6,094.47 | $16,380.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.30 / $2,498.50 / $3,611.80
| Professional | | $1,606.30 | $2,498.50 | $3,611.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,925.55 / $4,775.89 / $6,150.44
| Facility | | $3,925.55 | $4,775.89 | $6,150.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,421.81 / $3,281.58 / $3,281.58
| Professional | | $2,421.81 | $3,281.58 | $3,281.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,139.27 / $2,425.11 / $2,592.84
| Facility | | $2,139.27 | $2,425.11 | $2,592.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,425.11 / $4,346.25
| Professional | | $1,770.33 | $2,425.11 | $4,346.25 |
- 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
- $2,994.50 / $2,994.50 / $3,144.22
| Professional | | $2,994.50 | $2,994.50 | $3,144.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.00 / $2,114.00 / $2,114.00
| Professional | | $2,114.00 | $2,114.00 | $2,114.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,610.21 / $16,380.05 / $16,380.05
| Facility | | $7,610.21 | $16,380.05 | $16,380.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.72 / $1,976.98 / $3,611.80
| Professional | | $1,444.72 | $1,976.98 | $3,611.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.35 / $1,976.98 / $3,225.50
| Professional | | $1,575.35 | $1,976.98 | $3,225.50 |