- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $2,290.87
| Facility | | $1,412.54 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $4,073.80
| Professional | | $1,949.84 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,951.21
| Facility | | $2,398.83 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,890.45 / $3,890.45
| Facility | | $34.67 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $13,803.84
| Professional | | $2,187.76 | $3,388.44 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $16,595.87
| Facility | | $3,548.13 | $3,548.13 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,570.40 / $3,715.35
| Professional | | $1,778.28 | $2,570.40 | $3,715.35 |