- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,910.42 / $4,151.06 / $5,895.71
| Facility | | $3,910.42 | $4,151.06 | $5,895.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,319.15 / $4,151.06 / $6,016.03
| Professional | | $3,319.15 | $4,151.06 | $6,016.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,297.58 / $10,758.47 / $15,122.49
| Facility | | $6,297.58 | $10,758.47 | $15,122.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.74 / $5,137.07 / $5,137.07
| Professional | | $4,294.74 | $5,137.07 | $5,137.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $4,063.89 / $4,063.89
| Professional | | $3,454.31 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.08 / $3,609.62 / $4,999.87
| Professional | | $2,163.08 | $3,609.62 | $4,999.87 |