- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $3,094.52 / $3,094.52
| Facility | | $1,400.00 | $3,094.52 | $3,094.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,094.52 / $3,226.45 / $3,625.05
| Professional | | $3,094.52 | $3,226.45 | $3,625.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,086.96 / $3,529.58 / $3,845.54
| Facility | | $3,086.96 | $3,529.58 | $3,845.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,418.26 / $3,418.26 / $3,418.26
| Professional | | $3,418.26 | $3,418.26 | $3,418.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,309.40 / $3,309.40 / $3,309.40
| Facility | | $3,309.40 | $3,309.40 | $3,309.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,767.85 / $4,272.82 / $13,522.08
| Professional | | $2,767.85 | $4,272.82 | $13,522.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.51 / $3,573.28 / $4,901.12
| Professional | | $2,371.51 | $3,573.28 | $4,901.12 |