- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,980.38 / $1,980.38 / $5,084.77
| Facility | | $1,980.38 | $1,980.38 | $5,084.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.38 / $2,443.58 / $5,084.77
| Professional | | $1,980.38 | $2,443.58 | $5,084.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,112.58 / $6,112.58 / $6,112.58
| Facility | | $6,112.58 | $6,112.58 | $6,112.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.44 / $2,800.76 / $6,112.58
| Professional | | $2,753.44 | $2,800.76 | $6,112.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $4,499.93
| Facility | | $3,670.30 | $3,670.30 | $4,499.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $3,627.73 / $4,039.82
| Professional | | $2,679.32 | $3,627.73 | $4,039.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,399.14 / $4,890.06 / $7,946.35
| Professional | | $3,399.14 | $4,890.06 | $7,946.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.55 / $3,049.50 / $3,811.87
| Professional | | $2,131.55 | $3,049.50 | $3,811.87 |