- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,855.65 / $2,855.65 / $2,855.65
| Facility | | $2,855.65 | $2,855.65 | $2,855.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.06 / $1,988.11 / $3,180.98
| Professional | | $1,038.06 | $1,988.11 | $3,180.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,892.11 / $3,155.43 / $3,346.94
| Facility | | $2,892.11 | $3,155.43 | $3,346.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.02 / $3,132.02 / $3,132.02
| Professional | | $3,132.02 | $3,132.02 | $3,132.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,561.34 / $2,561.34
| Facility | | $2,561.34 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,561.34 / $5,629.69
| Professional | | $1,869.78 | $2,561.34 | $5,629.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.06 / $3,060.67 / $16,910.75
| Facility | | $1,038.06 | $3,060.67 | $16,910.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.97 / $2,153.56 / $4,851.82
| Professional | | $1,071.97 | $2,153.56 | $4,851.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.09 / $1,894.65 / $2,537.53
| Professional | | $1,263.09 | $1,894.65 | $2,537.53 |