- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.08 / $1,203.08 / $1,594.81
| Facility | | $1,203.08 | $1,203.08 | $1,594.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.08 / $1,426.68 / $1,594.81
| Professional | | $1,203.08 | $1,426.68 | $1,594.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.20 / $1,448.15 / $6,000.00
| Professional | | $1,310.20 | $1,448.15 | $6,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.04 / $2,705.67 / $4,211.85
| Professional | | $1,331.04 | $2,705.67 | $4,211.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,663.24 / $3,544.81 / $3,544.81
| Professional | | $2,663.24 | $3,544.81 | $3,544.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,261.00 / $4,165.00 / $26,408.00
| Facility | | $3,261.00 | $4,165.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.29 / $2,368.48 / $4,291.80
| Professional | | $1,360.29 | $2,368.48 | $4,291.80 |