- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.30 / $1,822.30 / $1,822.30
| Facility | | $1,822.30 | $1,822.30 | $1,822.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.23 / $1,822.30 / $1,959.97
| Professional | | $1,806.23 | $1,822.30 | $1,959.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,488.32 / $5,016.97 / $6,503.49
| Facility | | $2,488.32 | $5,016.97 | $6,503.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,415.58 / $2,679.73 / $4,593.82
| Professional | | $2,415.58 | $2,679.73 | $4,593.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $4,486.14
| Facility | | $2,463.07 | $2,463.07 | $4,486.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,463.07 / $18,260.96
| Professional | | $1,798.04 | $2,463.07 | $18,260.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.01 / $2,370.42 / $3,090.01
| Professional | | $1,854.01 | $2,370.42 | $3,090.01 |