- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,901.20 / $1,901.20 / $1,901.20
| Facility | | $1,901.20 | $1,901.20 | $1,901.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.20 / $1,901.20 / $3,223.50
| Professional | | $1,901.20 | $1,901.20 | $3,223.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,893.14 / $11,621.02 / $20,548.93
| Facility | | $3,893.14 | $11,621.02 | $20,548.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.46 / $3,302.27 / $4,249.32
| Professional | | $2,060.46 | $3,302.27 | $4,249.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,593.35 / $5,615.30 / $7,203.79
| Facility | | $4,593.35 | $5,615.30 | $7,203.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,971.79 / $3,860.82 / $3,860.82
| Professional | | $2,971.79 | $3,860.82 | $3,860.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $3,148.57 / $5,111.63
| Professional | | $2,298.46 | $3,148.57 | $5,111.63 |
- 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
- $3,523.06 / $3,523.06 / $3,699.21
| Professional | | $3,523.06 | $3,523.06 | $3,699.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,276.93 / $3,276.93 / $3,276.93
| Professional | | $3,276.93 | $3,276.93 | $3,276.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,951.00 / $20,548.93 / $20,548.93
| Facility | | $8,951.00 | $20,548.93 | $20,548.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.06 / $2,425.94 / $4,249.32
| Professional | | $1,717.06 | $2,425.94 | $4,249.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.02 / $2,484.98 / $4,249.32
| Professional | | $1,962.02 | $2,484.98 | $4,249.32 |