- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,229.36 / $3,229.36 / $4,603.25
| Facility | | $3,229.36 | $3,229.36 | $4,603.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.33 / $3,452.44 / $3,452.44
| Professional | | $1,239.33 | $3,452.44 | $3,452.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,904.86 / $6,904.86 / $6,904.86
| Facility | | $6,904.86 | $6,904.86 | $6,904.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.91 / $3,452.44 / $3,797.68
| Facility | | $2,152.91 | $3,452.44 | $3,797.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,770.48 / $2,124.58
| Professional | | $1,770.48 | $1,770.48 | $2,124.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.44 / $3,452.44 / $3,452.44
| Professional | | $3,452.44 | $3,452.44 | $3,452.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,655.72 / $4,426.20 / $6,373.73
| Facility | | $2,655.72 | $4,426.20 | $6,373.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,646.20 / $2,646.20 / $2,646.20
| Professional | | $2,646.20 | $2,646.20 | $2,646.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $743.60 / $2,832.77
| Professional | | $743.60 | $743.60 | $2,832.77 |