- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.60 / $2,202.60 / $4,570.39
| Facility | | $2,202.60 | $2,202.60 | $4,570.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.91 / $2,202.60 / $2,202.60
| Professional | | $1,830.91 | $2,202.60 | $2,202.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,092.05 / $3,832.55 / $7,228.23
| Facility | | $2,092.05 | $3,832.55 | $7,228.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.60 / $2,753.25 / $4,129.88
| Facility | | $2,202.60 | $2,753.25 | $4,129.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.61 / $1,789.61 / $2,753.25
| Professional | | $1,789.61 | $1,789.61 | $2,753.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.25 / $4,212.47 / $5,272.47
| Professional | | $2,753.25 | $4,212.47 | $5,272.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.63 / $1,651.95 / $3,579.23
| Professional | | $1,376.63 | $1,651.95 | $3,579.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,790.66 / $13,077.94 / $13,077.94
| Facility | | $4,790.66 | $13,077.94 | $13,077.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,711.19 / $13,711.19 / $20,649.38
| Professional | | $13,711.19 | $13,711.19 | $20,649.38 |