- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,866.07 / $1,866.07 / $1,866.07
| Facility | | $1,866.07 | $1,866.07 | $1,866.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.07 / $1,866.07 / $2,914.66
| Professional | | $1,866.07 | $1,866.07 | $2,914.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,602.05 / $8,227.33 / $19,856.05
| Facility | | $2,602.05 | $8,227.33 | $19,856.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.32 / $2,780.96 / $4,170.81
| Professional | | $1,836.32 | $2,780.96 | $4,170.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,663.35 / $5,515.07 / $7,102.37
| Facility | | $4,663.35 | $5,515.07 | $7,102.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.63 / $3,927.35 / $3,927.35
| Professional | | $2,796.63 | $3,927.35 | $3,927.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,024.96 / $3,214.74 / $3,214.74
| Facility | | $2,024.96 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $3,214.74 / $4,698.38
| Professional | | $2,732.53 | $3,214.74 | $4,698.38 |
- 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
- $3,457.97 / $3,457.97 / $3,630.87
| Professional | | $3,457.97 | $3,457.97 | $3,630.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,227.33 / $19,856.05 / $19,856.05
| Facility | | $8,227.33 | $19,856.05 | $19,856.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.32 / $2,282.96 / $4,170.81
| Professional | | $1,668.32 | $2,282.96 | $4,170.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.32 / $2,282.96 / $4,170.81
| Professional | | $1,668.32 | $2,282.96 | $4,170.81 |