- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,174.01 / $2,174.01 / $2,174.01
| Facility | | $2,174.01 | $2,174.01 | $2,174.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.01 / $2,770.64 / $2,770.64
| Professional | | $2,174.01 | $2,770.64 | $2,770.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,793.91 / $3,303.38 / $3,385.56
| Professional | | $2,793.91 | $3,303.38 | $3,385.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,834.75 / $3,873.10 / $4,870.13
| Professional | | $3,834.75 | $3,873.10 | $4,870.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.12 / $2,562.42 / $14,469.30
| Facility | | $1,520.12 | $2,562.42 | $14,469.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.44 / $2,061.29 / $2,416.58
| Professional | | $1,190.44 | $2,061.29 | $2,416.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.91 / $1,815.91 / $1,815.91
| Facility | | $1,815.91 | $1,815.91 | $1,815.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.13 / $1,375.21 / $2,380.87
| Professional | | $916.13 | $1,375.21 | $2,380.87 |