- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.28 / $1,365.28 / $3,505.44
| Facility | | $1,365.28 | $1,365.28 | $3,505.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.28 / $1,896.31 / $3,505.44
| Professional | | $1,365.28 | $1,896.31 | $3,505.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,214.02 / $4,214.02 / $4,214.02
| Facility | | $4,214.02 | $4,214.02 | $4,214.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,530.96 / $2,578.42 / $5,618.69
| Professional | | $2,530.96 | $2,578.42 | $5,618.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $3,102.26
| Facility | | $2,741.63 | $2,741.63 | $3,102.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $2,855.60
| Professional | | $2,001.39 | $2,741.63 | $2,855.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,343.37 / $3,503.88 / $6,068.19
| Professional | | $2,343.37 | $3,503.88 | $6,068.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.77 / $2,250.64 / $3,239.62
| Professional | | $1,943.77 | $2,250.64 | $3,239.62 |