- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.51 / $1,701.51 / $1,701.51
| Facility | | $1,701.51 | $1,701.51 | $1,701.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.26 / $1,243.29 / $1,701.51
| Professional | | $1,130.26 | $1,243.29 | $1,701.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.67 / $2,585.42 / $2,649.74
| Professional | | $2,186.67 | $2,585.42 | $2,649.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.50 / $2,431.58 / $3,057.53
| Professional | | $2,407.50 | $2,431.58 | $3,057.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.70 / $1,701.51 / $10,083.62
| Facility | | $1,006.70 | $1,701.51 | $10,083.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.48 / $1,042.31 / $1,863.40
| Professional | | $852.48 | $1,042.31 | $1,863.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.90 / $938.86 / $1,863.40
| Professional | | $625.90 | $938.86 | $1,863.40 |