- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,480.53 / $1,509.56 / $1,509.56
| Facility | | $1,480.53 | $1,509.56 | $1,509.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.62 / $1,509.56 / $2,593.39
| Professional | | $1,443.62 | $1,509.56 | $2,593.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,076.03 / $3,135.95 / $3,135.95
| Professional | | $2,076.03 | $3,135.95 | $3,135.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,641.51 / $2,571.77 / $2,571.77
| Facility | | $1,641.51 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $1,877.39 / $2,571.77
| Professional | | $1,877.39 | $1,877.39 | $2,571.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,703.93 / $16,090.64 / $16,090.64
| Facility | | $4,703.93 | $16,090.64 | $16,090.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,470.80 / $17,890.11 / $23,031.75
| Professional | | $17,470.80 | $17,890.11 | $23,031.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.88 / $1,738.33 / $2,398.03
| Professional | | $1,158.88 | $1,738.33 | $2,398.03 |