- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,936.44 / $2,936.44 / $5,843.52
| Facility | | $2,936.44 | $2,936.44 | $5,843.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,936.44 / $2,936.44 / $2,936.44
| Professional | | $2,936.44 | $2,936.44 | $2,936.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.75 / $1,354.50 / $2,148.00
| Facility | | $858.75 | $1,354.50 | $2,148.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.63 / $3,081.45 / $3,081.45
| Professional | | $1,456.63 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,301.91 / $2,936.44 / $4,199.10
| Facility | | $2,301.91 | $2,936.44 | $4,199.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,021.04
| Professional | | $3,021.04 | $3,021.04 | $3,021.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.94 / $3,021.04 / $3,021.04
| Professional | | $2,718.94 | $3,021.04 | $3,021.04 |