- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.02 / $1,770.02 / $1,770.02
| Facility | | $1,770.02 | $1,770.02 | $1,770.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.84 / $1,770.02 / $1,770.02
| Professional | | $1,627.84 | $1,770.02 | $1,770.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,035.60 / $4,440.87 / $5,551.09
| Professional | | $4,035.60 | $4,440.87 | $5,551.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.14 / $2,338.39 / $4,262.20
| Facility | | $1,217.14 | $2,338.39 | $4,262.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.26 / $3,531.38 / $12,087.04
| Professional | | $1,942.26 | $3,531.38 | $12,087.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.74 / $4,006.98 / $5,182.89
| Facility | | $2,658.74 | $4,006.98 | $5,182.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,993.08 / $4,159.22 / $5,182.89
| Professional | | $2,993.08 | $4,159.22 | $5,182.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.26 / $3,149.84 / $3,818.42
| Professional | | $1,942.26 | $3,149.84 | $3,818.42 |