- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,346.92 / $2,346.92 / $3,459.05
| Facility | | $2,346.92 | $2,346.92 | $3,459.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.00 / $2,346.92 / $2,645.88
| Professional | | $2,260.00 | $2,346.92 | $2,645.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $5,723.63
| Professional | | $2,012.35 | $2,012.35 | $5,723.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,420.87 / $2,981.06 / $22,996.26
| Facility | | $1,420.87 | $2,981.06 | $22,996.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.28 / $2,365.81 / $4,909.06
| Professional | | $1,467.28 | $2,365.81 | $4,909.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.28 / $2,200.91 / $3,157.49
| Professional | | $1,467.28 | $2,200.91 | $3,157.49 |