- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $3,528.74 / $6,621.44
| Facility | | $2,016.42 | $3,528.74 | $6,621.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.32 / $2,016.42 / $2,240.23
| Professional | | $1,996.32 | $2,016.42 | $2,240.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,076.92 / $7,757.54 / $38,442.47
| Facility | | $5,076.92 | $7,757.54 | $38,442.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.30 / $2,016.42 / $2,918.15
| Professional | | $1,476.30 | $2,016.42 | $2,918.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.35 / $2,621.35 / $2,621.35
| Professional | | $2,621.35 | $2,621.35 | $2,621.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,210.67
| Professional | | $2,016.42 | $2,016.42 | $2,210.67 |