- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $5,074.71
| Facility | | $3,739.65 | $3,739.65 | $5,074.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,519.67 / $3,739.65 / $4,179.60
| Professional | | $3,519.67 | $3,739.65 | $4,179.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.06 / $1,497.05 / $2,498.40
| Facility | | $497.06 | $1,497.05 | $2,498.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.87 / $3,666.33 / $6,514.12
| Professional | | $451.87 | $3,666.33 | $6,514.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $589.19 / $1,009.12 / $1,858.76
| Facility | | $589.19 | $1,009.12 | $1,858.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Facility | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.91 / $888.94 / $6,679.00
| Facility | | $460.91 | $888.94 | $6,679.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.52 / $632.62 / $915.67
| Professional | | $518.52 | $632.62 | $915.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $6,032.06
| Professional | | $3,739.65 | $3,739.65 | $6,032.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,179.60 / $4,179.60 / $8,799.18
| Facility | | $4,179.60 | $4,179.60 | $8,799.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $16,718.43
| Professional | | $3,666.33 | $3,666.33 | $16,718.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $5,499.50
| Professional | | $3,666.33 | $3,666.33 | $5,499.50 |