- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $2,951.21
| Professional | | $1,698.24 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $7,943.28
| Facility | | $3,311.31 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,019.95
| Professional | | $2,951.21 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,235.94 / $3,235.94
| Facility | | $851.14 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $4,677.35
| Professional | | $2,754.23 | $2,754.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,949.84 / $2,691.53
| Professional | | $1,819.70 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,235.94 / $5,754.40
| Facility | | $1,659.59 | $3,235.94 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,398.83 / $3,162.28
| Facility | | $954.99 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $2,818.38
| Professional | | $1,548.82 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,379.62 / $21,379.62 / $33,113.11
| Professional | | $21,379.62 | $21,379.62 | $33,113.11 |