- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,485.96 / $4,723.34 / $6,576.43
| Facility | | $2,485.96 | $4,723.34 | $6,576.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,545.87
| Professional | | $2,396.11 | $2,485.96 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.95 / $2,620.75 / $7,962.08
| Facility | | $346.95 | $2,620.75 | $7,962.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.95 / $346.95 / $2,545.87
| Professional | | $346.95 | $346.95 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.91 / $2,545.87 / $2,545.87
| Professional | | $452.91 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,485.96 / $2,545.87 / $2,995.14
| Professional | | $2,485.96 | $2,545.87 | $2,995.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,645.71
| Professional | | $2,495.94 | $2,495.94 | $2,645.71 |