- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,252.62 / $2,252.62 / $5,783.74
| Facility | | $2,252.62 | $2,252.62 | $5,783.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.62 / $2,881.78 / $5,783.74
| Professional | | $2,252.62 | $2,881.78 | $5,783.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,952.84 / $6,952.84 / $6,952.84
| Facility | | $6,952.84 | $6,952.84 | $6,952.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.00 / $3,171.15 / $6,952.84
| Professional | | $3,132.00 | $3,171.15 | $6,952.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $5,118.51
| Facility | | $3,745.37 | $3,745.37 | $5,118.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $5,044.39
| Professional | | $2,734.12 | $2,734.12 | $5,044.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,866.39 / $5,562.27 / $9,038.69
| Professional | | $3,866.39 | $5,562.27 | $9,038.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.32 / $2,601.52 / $4,335.87
| Professional | | $2,405.32 | $2,601.52 | $4,335.87 |