- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.01 / $1,686.44 / $1,686.44
| Facility | | $1,654.01 | $1,686.44 | $1,686.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.73 / $1,686.44 / $3,042.51
| Professional | | $1,634.73 | $1,686.44 | $3,042.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.29 / $3,503.39 / $3,503.39
| Professional | | $2,319.29 | $3,503.39 | $3,503.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,979.65 / $2,970.85 / $2,970.85
| Facility | | $1,979.65 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,168.71 / $2,970.85
| Professional | | $2,168.71 | $2,168.71 | $2,970.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,135.71 / $19,143.40 / $19,545.97
| Facility | | $6,135.71 | $19,143.40 | $19,545.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,162.56 / $24,162.56 / $28,780.73
| Professional | | $24,162.56 | $24,162.56 | $28,780.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.67 / $1,901.48 / $2,783.19
| Professional | | $1,294.67 | $1,901.48 | $2,783.19 |