- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,235.94
| Professional | | $1,348.96 | $1,905.46 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $5,623.41
| Professional | | $1,819.70 | $1,819.70 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $5,128.61
| Professional | | $2,754.23 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,570.40 / $3,981.07
| Facility | | $1,023.29 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $4,677.35
| Professional | | $1,819.70 | $1,819.70 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,398.83 / $4,365.16
| Facility | | $1,230.27 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $2,398.83
| Professional | | $1,479.11 | $1,819.70 | $2,398.83 |