- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.44 / $1,045.44 / $2,684.23
| Facility | | $1,045.44 | $1,045.44 | $2,684.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.44 / $1,452.06 / $2,684.23
| Professional | | $1,045.44 | $1,452.06 | $2,684.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,226.81 / $3,226.81 / $3,226.81
| Facility | | $3,226.81 | $3,226.81 | $3,226.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.42 / $1,696.36 / $3,719.39
| Professional | | $1,675.42 | $1,696.36 | $3,719.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $2,375.50
| Facility | | $1,743.07 | $1,743.07 | $2,375.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $3,100.66
| Professional | | $1,272.44 | $1,272.44 | $3,100.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.39 / $2,581.44 / $4,194.85
| Professional | | $1,794.39 | $2,581.44 | $4,194.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.72 / $1,391.68 / $2,156.06
| Professional | | $1,286.72 | $1,391.68 | $2,156.06 |