- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.46 / $2,900.69 / $2,900.69
| Professional | | $2,150.46 | $2,900.69 | $2,900.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $3,047.80
| Facility | | $1,850.09 | $1,850.09 | $3,047.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,648.75 / $3,685.24 / $4,560.93
| Professional | | $3,648.75 | $3,685.24 | $4,560.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,145.80 / $5,892.29 / $16,606.15
| Facility | | $3,145.80 | $5,892.29 | $16,606.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.33 / $2,591.90 / $4,166.85
| Professional | | $1,814.33 | $2,591.90 | $4,166.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.74 / $346.04 / $346.04
| Facility | | $344.74 | $346.04 | $346.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.74 / $655.01 / $3,593.01
| Professional | | $344.74 | $655.01 | $3,593.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.95 / $2,591.90 / $4,005.87
| Professional | | $1,295.95 | $2,591.90 | $4,005.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.22 / $2,831.22 / $2,831.22
| Professional | | $2,831.22 | $2,831.22 | $2,831.22 |