- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,235.94
| Facility | | $2,344.23 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $3,235.94
| Professional | | $1,445.44 | $1,949.84 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,630.78 / $3,981.07
| Professional | | $2,691.53 | $3,630.78 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $5,623.41
| Professional | | $4,466.84 | $4,466.84 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,235.94 / $16,982.44
| Facility | | $1,737.80 | $3,235.94 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $3,235.94
| Professional | | $1,288.25 | $1,621.81 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $5,248.07
| Facility | | $2,137.96 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $4,168.69
| Professional | | $1,258.93 | $2,398.83 | $4,168.69 |