- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.71 / $2,104.71 / $2,104.71
| Facility | | $2,104.71 | $2,104.71 | $2,104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.71 / $2,219.81 / $3,833.07
| Professional | | $2,104.71 | $2,219.81 | $3,833.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.63 / $10,018.87 / $22,982.54
| Facility | | $3,183.63 | $10,018.87 | $22,982.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.56 / $3,488.48 / $4,704.18
| Professional | | $2,199.56 | $3,488.48 | $4,704.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,259.71 / $6,220.35 / $8,010.63
| Facility | | $5,259.71 | $6,220.35 | $8,010.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,154.28 / $4,274.09 / $4,274.09
| Professional | | $3,154.28 | $4,274.09 | $4,274.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $3,540.51
| Facility | | $2,801.20 | $2,801.20 | $3,540.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $5,721.75
| Professional | | $2,044.88 | $2,044.88 | $5,721.75 |
- 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
- $3,900.18 / $3,900.18 / $4,095.19
| Professional | | $3,900.18 | $3,900.18 | $4,095.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,478.40 / $3,478.40 / $3,478.40
| Professional | | $3,478.40 | $3,478.40 | $3,478.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,018.87 / $22,982.54 / $22,982.54
| Facility | | $10,018.87 | $22,982.54 | $22,982.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.68 / $2,574.92 / $4,704.18
| Professional | | $1,881.68 | $2,574.92 | $4,704.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.12 / $2,583.35 / $4,704.18
| Professional | | $2,092.12 | $2,583.35 | $4,704.18 |