- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,454.71
| Facility | | $2,398.83 | $2,398.83 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $2,454.71
| Professional | | $1,819.70 | $2,398.83 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,754.23
| Professional | | $2,187.76 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $2,344.23 / $6,918.31
| Facility | | $147.91 | $2,344.23 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $2,754.23
| Professional | | $2,344.23 | $2,570.40 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $2,884.03
| Professional | | $2,344.23 | $2,570.40 | $2,884.03 |