- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,279.12 / $2,279.12
| Facility | | $1,400.00 | $2,279.12 | $2,279.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.67 / $2,279.12 / $2,747.58
| Professional | | $2,064.67 | $2,279.12 | $2,747.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.92 / $3,003.18 / $3,272.01
| Facility | | $2,571.92 | $3,003.18 | $3,272.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.45 / $2,908.45 / $2,908.45
| Professional | | $2,908.45 | $2,908.45 | $2,908.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.52 / $2,756.52 / $2,756.52
| Facility | | $2,756.52 | $2,756.52 | $2,756.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.69 / $3,635.56 / $13,163.85
| Professional | | $2,311.69 | $3,635.56 | $13,163.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,998.81 / $2,888.39 / $3,974.43
| Professional | | $1,998.81 | $2,888.39 | $3,974.43 |