- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.18 / $3,340.18 / $3,340.18
| Facility | | $3,340.18 | $3,340.18 | $3,340.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.07 / $2,325.44 / $3,720.71
| Professional | | $1,173.07 | $2,325.44 | $3,720.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.91 / $4,303.01 / $4,564.16
| Facility | | $3,943.91 | $4,303.01 | $4,564.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,271.08 / $4,271.08 / $4,271.08
| Professional | | $4,271.08 | $4,271.08 | $4,271.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $3,141.52
| Facility | | $3,141.52 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,141.52 / $7,037.34
| Professional | | $2,293.31 | $3,141.52 | $7,037.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.07 / $3,580.00 / $18,963.50
| Facility | | $1,173.07 | $3,580.00 | $18,963.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.39 / $2,433.65 / $5,675.09
| Professional | | $1,211.39 | $2,433.65 | $5,675.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.42 / $2,216.12 / $2,881.88
| Professional | | $1,477.42 | $2,216.12 | $2,881.88 |