- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,333.04 / $2,333.04 / $2,333.04
| Facility | | $2,333.04 | $2,333.04 | $2,333.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,333.04 / $2,333.04 / $2,750.90
| Professional | | $2,333.04 | $2,333.04 | $2,750.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,215.42 / $3,536.96 / $3,572.69
| Professional | | $3,215.42 | $3,536.96 | $3,572.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $4,024.27 / $4,024.27
| Facility | | $2,637.76 | $4,024.27 | $4,024.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,637.76 / $4,024.27 / $6,205.52
| Professional | | $2,637.76 | $4,024.27 | $6,205.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,042.90 / $4,004.47 / $17,548.22
| Facility | | $2,042.90 | $4,004.47 | $17,548.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.86 / $2,205.14 / $3,041.92
| Professional | | $1,392.86 | $2,205.14 | $3,041.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,012.51 / $4,024.27 / $5,070.47
| Facility | | $4,012.51 | $4,024.27 | $5,070.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,643.69 / $4,823.13 / $8,290.67
| Professional | | $3,643.69 | $4,823.13 | $8,290.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.86 / $1,825.15 / $2,863.37
| Professional | | $1,392.86 | $1,825.15 | $2,863.37 |