- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $2,691.53
| Facility | | $2,137.96 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $2,754.23
| Professional | | $1,513.56 | $2,398.83 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,897.79 / $5,128.61
| Professional | | $3,715.35 | $4,897.79 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $5,128.61
| Professional | | $4,168.69 | $4,168.69 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $2,754.23 / $18,197.01
| Facility | | $245.47 | $2,754.23 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $2,884.03
| Professional | | $1,380.38 | $1,698.24 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $1,698.24 / $2,290.87
| Facility | | $229.09 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,905.46 / $3,981.07
| Professional | | $1,380.38 | $1,905.46 | $3,981.07 |