- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.17 / $2,203.17 / $2,203.17
| Facility | | $2,203.17 | $2,203.17 | $2,203.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.65 / $2,203.17 / $2,508.23
| Professional | | $1,723.65 | $2,203.17 | $2,508.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.80 / $1,893.62 / $2,403.00
| Professional | | $1,850.80 | $1,893.62 | $2,403.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.95 / $419.63 / $3,550.68
| Facility | | $225.95 | $419.63 | $3,550.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.81 / $387.35 / $3,486.13
| Professional | | $209.81 | $387.35 | $3,486.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,387.48 / $2,387.48
| Professional | | $251.77 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.81 / $1,176.08 / $2,069.48
| Professional | | $761.81 | $1,176.08 | $2,069.48 |