- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,890.89 / $1,927.96 / $1,927.96
| Facility | | $1,890.89 | $1,927.96 | $1,927.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.89 / $2,060.84 / $3,347.07
| Professional | | $1,890.89 | $2,060.84 | $3,347.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,651.44 / $4,005.14 / $4,005.14
| Professional | | $2,651.44 | $4,005.14 | $4,005.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,378.78 / $2,780.72 / $2,780.72
| Facility | | $2,378.78 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,029.93 / $2,780.72
| Professional | | $2,029.93 | $2,029.93 | $2,780.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,836.17 / $23,421.34 / $24,060.65
| Facility | | $7,836.17 | $23,421.34 | $24,060.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29,548.98 / $29,548.98 / $43,828.28
| Professional | | $29,548.98 | $29,548.98 | $43,828.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.08 / $2,220.13 / $3,345.05
| Professional | | $1,480.08 | $2,220.13 | $3,345.05 |