- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.69 / $1,953.69 / $1,953.69
| Facility | | $1,953.69 | $1,953.69 | $1,953.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,953.69 / $2,620.38 / $23,335.70
| Professional | | $1,953.69 | $2,620.38 | $23,335.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $3,790.37
| Facility | | $3,790.37 | $3,790.37 | $3,790.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $3,790.37 / $4,197.97
| Professional | | $2,766.97 | $3,790.37 | $4,197.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,295.42 / $5,315.20 / $6,909.76
| Professional | | $3,295.42 | $5,315.20 | $6,909.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,375.36 / $7,110.20 / $7,110.20
| Facility | | $6,375.36 | $7,110.20 | $7,110.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,048.79 / $5,096.59 / $7,644.88
| Professional | | $4,048.79 | $5,096.59 | $7,644.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.44 / $3,026.25 / $4,341.54
| Professional | | $2,732.44 | $3,026.25 | $4,341.54 |