- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,238.72
| Facility | | $2,187.76 | $2,187.76 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,238.72
| Professional | | $1,445.44 | $1,737.80 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $3,715.35
| Professional | | $2,511.89 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,677.35
| Professional | | $3,715.35 | $3,715.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,884.03 / $15,135.61
| Facility | | $1,445.44 | $2,884.03 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $3,019.95
| Professional | | $1,202.26 | $1,513.56 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,786.30 / $4,786.30
| Facility | | $1,445.44 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,467.37
| Professional | | $1,148.15 | $1,513.56 | $3,467.37 |