- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $17,378.01 / $17,378.01
| Facility | | $3,715.35 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,897.79
| Professional | | $2,570.40 | $3,235.94 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $11,220.18
| Facility | | $6,309.57 | $6,309.57 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $8,317.64 / $10,232.93
| Professional | | $3,890.45 | $8,317.64 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $5,370.32
| Facility | | $3,890.45 | $3,890.45 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,265.80 / $5,370.32
| Professional | | $3,311.31 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $6,025.60
| Facility | | $3,467.37 | $4,265.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,370.32 / $10,232.93
| Facility | | $2,884.03 | $5,370.32 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $4,265.80 / $5,370.32
| Professional | | $79.43 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $11,748.98 / $15,135.61
| Facility | | $6,760.83 | $11,748.98 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,311.31 / $4,677.35
| Professional | | $3,090.30 | $3,311.31 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $6,165.95
| Facility | | $4,677.35 | $4,677.35 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $4,677.35
| Professional | | $1,621.81 | $1,621.81 | $4,677.35 |