- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,234.02 / $3,234.02 / $3,234.02
| Facility | | $3,234.02 | $3,234.02 | $3,234.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,234.02 / $3,533.19 / $5,562.19
| Professional | | $3,234.02 | $3,533.19 | $5,562.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,100.00 / $12,931.40 / $37,094.85
| Facility | | $4,100.00 | $12,931.40 | $37,094.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,555.35 / $5,478.69 / $7,228.27
| Professional | | $3,555.35 | $5,478.69 | $7,228.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,856.18 / $9,557.95 / $12,308.83
| Facility | | $7,856.18 | $9,557.95 | $12,308.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,846.72 / $6,567.40 / $6,567.40
| Professional | | $4,846.72 | $6,567.40 | $6,567.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,281.32 / $4,938.58 / $5,189.03
| Facility | | $4,281.32 | $4,938.58 | $5,189.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $4,938.58 / $8,850.37
| Professional | | $3,605.16 | $4,938.58 | $8,850.37 |
- 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
- $5,992.87 / $5,992.87 / $6,292.51
| Professional | | $5,992.87 | $5,992.87 | $6,292.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,604.19 / $5,604.19 / $5,604.19
| Professional | | $5,604.19 | $5,604.19 | $5,604.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,497.73 / $37,094.85 / $37,094.85
| Facility | | $15,497.73 | $37,094.85 | $37,094.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,962.80 / $3,956.51 / $7,228.27
| Professional | | $2,962.80 | $3,956.51 | $7,228.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,555.35 / $5,478.69 / $6,579.39
| Professional | | $3,555.35 | $5,478.69 | $6,579.39 |