- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.00 / $4,213.50 / $7,552.50
| Facility | | $1,855.00 | $4,213.50 | $7,552.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.50 / $1,742.38 / $2,252.50
| Professional | | $1,404.50 | $1,742.38 | $2,252.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $208.00 / $582.40
| Professional | | $208.00 | $208.00 | $582.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,180.00 / $5,598.13 / $9,540.54
| Facility | | $3,180.00 | $5,598.13 | $9,540.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,227.75 / $12,773.00 / $12,773.00
| Professional | | $3,227.75 | $12,773.00 | $12,773.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.00 / $3,180.00 / $5,962.50
| Facility | | $294.00 | $3,180.00 | $5,962.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,782.50 / $3,471.50 / $5,750.50
| Professional | | $2,782.50 | $3,471.50 | $5,750.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.50 / $2,650.00 / $4,805.22
| Professional | | $2,252.50 | $2,650.00 | $4,805.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.00 / $5,598.13 / $9,540.54
| Facility | | $555.00 | $5,598.13 | $9,540.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.50 / $2,862.00 / $6,095.00
| Professional | | $1,722.50 | $2,862.00 | $6,095.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.00 / $1,590.00 / $4,016.29
| Professional | | $1,113.00 | $1,590.00 | $4,016.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,800.69 / $3,047.43 / $3,047.43
| Facility | | $2,800.69 | $3,047.43 | $3,047.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.50 / $2,800.69 / $3,195.42
| Professional | | $2,252.50 | $2,800.69 | $3,195.42 |