- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,981.07
| Facility | | $1,548.82 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,754.23
| Professional | | $1,548.82 | $1,548.82 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,466.84 / $5,011.87
| Professional | | $3,235.94 | $4,466.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,235.94
| Professional | | $2,570.40 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,630.27 / $10,471.29
| Facility | | $1,548.82 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $3,801.89
| Professional | | $933.25 | $1,122.02 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,238.72 / $3,235.94
| Professional | | $933.25 | $2,238.72 | $3,235.94 |