- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,466.50 / $1,466.50 / $3,765.33
| Facility | | $1,466.50 | $1,466.50 | $3,765.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.50 / $1,972.40 / $3,765.33
| Professional | | $1,466.50 | $1,972.40 | $3,765.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,526.45 / $4,526.45 / $4,526.45
| Facility | | $4,526.45 | $4,526.45 | $4,526.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.71 / $2,260.71 / $4,933.93
| Professional | | $2,260.71 | $2,260.71 | $4,933.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $3,332.26
| Facility | | $2,717.61 | $2,717.61 | $3,332.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $2,991.53
| Professional | | $1,983.86 | $2,717.61 | $2,991.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.10 / $3,621.16 / $5,884.39
| Professional | | $2,517.10 | $3,621.16 | $5,884.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.49 / $1,846.11 / $3,024.44
| Professional | | $1,445.49 | $1,846.11 | $3,024.44 |