- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,871.54 / $2,871.54 / $3,965.46
| Facility | | $2,871.54 | $2,871.54 | $3,965.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.40 / $2,871.54 / $2,871.54
| Professional | | $1,367.40 | $2,871.54 | $2,871.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,598.06 / $2,598.06 / $2,598.06
| Facility | | $2,598.06 | $2,598.06 | $2,598.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.58 / $3,076.65 / $3,418.50
| Professional | | $2,324.58 | $3,076.65 | $3,418.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.35 / $1,718.37 / $4,088.53
| Facility | | $1,481.35 | $1,718.37 | $4,088.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,051.10 / $2,051.10 / $2,051.10
| Facility | | $2,051.10 | $2,051.10 | $2,051.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $1,367.40 / $2,292.56
| Professional | | $957.18 | $1,367.40 | $2,292.56 |