- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,907.21 / $1,907.21 / $1,907.21
| Facility | | $1,907.21 | $1,907.21 | $1,907.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.13 / $1,907.21 / $1,941.81
| Professional | | $1,815.13 | $1,907.21 | $1,941.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,688.62 / $13,182.53 / $23,114.40
| Facility | | $8,688.62 | $13,182.53 | $23,114.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,053.00 / $3,954.00 / $16,084.11
| Facility | | $3,053.00 | $3,954.00 | $16,084.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.24 / $3,180.70 / $5,803.44
| Professional | | $1,548.24 | $3,180.70 | $5,803.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.16 / $4,287.58 / $8,486.56
| Professional | | $1,810.16 | $4,287.58 | $8,486.56 |