- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,036.10 / $2,036.10 / $2,036.10
| Facility | | $2,036.10 | $2,036.10 | $2,036.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.04 / $1,725.59 / $2,036.10
| Professional | | $1,507.04 | $1,725.59 | $2,036.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,246.67 / $4,189.25 / $4,792.92
| Facility | | $3,246.67 | $4,189.25 | $4,792.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.57 / $2,072.57 / $2,164.90
| Professional | | $2,072.57 | $2,072.57 | $2,164.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $2,782.58 / $2,782.58
| Facility | | $2,782.58 | $2,782.58 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $2,031.28
| Professional | | $2,031.28 | $2,031.28 | $2,031.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,723.01 / $2,723.01 / $2,723.01
| Facility | | $2,723.01 | $2,723.01 | $2,723.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250.96 / $2,723.01 / $3,560.86
| Professional | | $2,250.96 | $2,723.01 | $3,560.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.60 / $2,225.60 / $2,225.60
| Professional | | $2,225.60 | $2,225.60 | $2,225.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.96 / $2,089.96 / $2,608.07
| Professional | | $1,594.96 | $2,089.96 | $2,608.07 |