- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,392.91 / $2,392.91 / $2,392.91
| Facility | | $2,392.91 | $2,392.91 | $2,392.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.91 / $1,756.50 / $2,392.91
| Professional | | $1,221.91 | $1,756.50 | $2,392.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,799.53 / $5,799.53 / $5,799.53
| Professional | | $5,799.53 | $5,799.53 | $5,799.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Facility | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.13 / $2,217.64 / $3,824.06
| Professional | | $2,074.13 | $2,217.64 | $3,824.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.67 / $2,240.17 / $12,404.85
| Facility | | $1,613.67 | $2,240.17 | $12,404.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.71 / $1,324.07 / $2,206.78
| Professional | | $882.71 | $1,324.07 | $2,206.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.71 / $1,324.07 / $2,132.76
| Professional | | $882.71 | $1,324.07 | $2,132.76 |