- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,228.87 / $5,228.87 / $5,228.87
| Facility | | $5,228.87 | $5,228.87 | $5,228.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.53 / $5,228.87 / $5,228.87
| Professional | | $2,736.53 | $5,228.87 | $5,228.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,894.64 / $5,166.56 / $5,438.50
| Professional | | $4,894.64 | $5,166.56 | $5,438.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $3,952.20 / $3,969.52
| Facility | | $200.00 | $3,952.20 | $3,969.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,952.20 / $5,064.75 / $8,118.75
| Professional | | $3,952.20 | $5,064.75 | $8,118.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.87 / $5,228.87 / $21,533.82
| Facility | | $510.87 | $5,228.87 | $21,533.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.62 / $2,656.29 / $4,608.35
| Professional | | $1,505.62 | $2,656.29 | $4,608.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.39 / $818.11 / $1,545.78
| Facility | | $812.39 | $818.11 | $1,545.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.11 / $1,010.77 / $1,933.72
| Professional | | $818.11 | $1,010.77 | $1,933.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.66 / $2,765.01 / $4,608.35
| Professional | | $2,103.66 | $2,765.01 | $4,608.35 |