- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $3,019.95
| Facility | | $1,862.09 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $1,819.70
| Professional | | $1,023.29 | $1,412.54 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $891.25 / $1,202.26
| Professional | | $208.93 | $891.25 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,238.72
| Professional | | $1,862.09 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $1,819.70
| Professional | | $1,023.29 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,862.09 / $2,691.53
| Professional | | $1,122.02 | $1,862.09 | $2,691.53 |