- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $3,205.30 / $4,881.93
| Facility | | $1,400.00 | $3,205.30 | $4,881.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,861.25 / $3,205.30 / $4,161.21
| Professional | | $2,861.25 | $3,205.30 | $4,161.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,303.79 / $3,780.71 / $4,119.13
| Facility | | $3,303.79 | $3,780.71 | $4,119.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.52 / $3,661.45 / $3,661.45
| Professional | | $1,878.52 | $3,661.45 | $3,661.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,539.93 / $3,539.93 / $3,539.93
| Facility | | $3,539.93 | $3,539.93 | $3,539.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.18 / $4,183.42 / $8,749.94
| Professional | | $2,734.18 | $4,183.42 | $8,749.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.23 / $3,468.18 / $4,966.67
| Professional | | $2,403.23 | $3,468.18 | $4,966.67 |