- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.01 / $2,090.01 / $2,090.01
| Facility | | $2,090.01 | $2,090.01 | $2,090.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.01 / $2,090.01 / $3,264.43
| Professional | | $2,090.01 | $2,090.01 | $3,264.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.31 / $9,214.64 / $22,238.84
| Facility | | $2,914.31 | $9,214.64 | $22,238.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.67 / $3,114.68 / $4,671.31
| Professional | | $2,056.67 | $3,114.68 | $4,671.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,222.95 / $6,176.88 / $7,954.65
| Facility | | $5,222.95 | $6,176.88 | $7,954.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.23 / $4,398.64 / $4,398.64
| Professional | | $3,132.23 | $4,398.64 | $4,398.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,267.94 / $3,600.52 / $3,600.52
| Facility | | $2,267.94 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,600.52 / $5,262.38
| Professional | | $3,060.44 | $3,600.52 | $5,262.38 |
- 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
- $3,872.92 / $3,872.92 / $4,066.57
| Professional | | $3,872.92 | $3,872.92 | $4,066.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,214.64 / $22,238.84 / $22,238.84
| Facility | | $9,214.64 | $22,238.84 | $22,238.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.52 / $2,556.92 / $4,671.31
| Professional | | $1,868.52 | $2,556.92 | $4,671.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.52 / $2,556.92 / $4,671.31
| Professional | | $1,868.52 | $2,556.92 | $4,671.31 |