- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $6,760.83
| Facility | | $4,677.35 | $4,677.35 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,398.83 / $5,011.87
| Professional | | $1,412.54 | $2,398.83 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,786.30 / $9,332.54
| Facility | | $2,570.40 | $4,786.30 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,630.27 / $2,630.27
| Professional | | $2,570.40 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,370.32 / $10,000.00
| Facility | | $1,995.26 | $5,370.32 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $5,011.87
| Facility | | $2,570.40 | $2,570.40 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $3,090.30
| Professional | | $2,398.83 | $2,691.53 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $77.62
| Professional | | $30.20 | $30.20 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $9,332.54
| Facility | | $3,890.45 | $4,786.30 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,691.53
| Professional | | $2,187.76 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $2,570.40
| Professional | | $1,071.52 | $1,071.52 | $2,570.40 |