- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,090.30
| Facility | | $2,454.71 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $3,162.28
| Professional | | $1,513.56 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,801.89 / $4,168.69
| Professional | | $2,818.38 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,370.32
| Professional | | $4,265.80 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,388.44 / $16,982.44
| Facility | | $1,513.56 | $3,388.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $3,388.44
| Professional | | $1,348.96 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $5,370.32
| Facility | | $2,187.76 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $3,981.07
| Professional | | $1,288.25 | $2,454.71 | $3,981.07 |