- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,478.33 / $1,478.33 / $1,478.33
| Facility | | $1,478.33 | $1,478.33 | $1,478.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.33 / $1,689.52 / $1,705.49
| Professional | | $1,478.33 | $1,689.52 | $1,705.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.86 / $3,017.00 / $3,017.00
| Professional | | $2,052.86 | $3,017.00 | $3,017.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,217.07
| Facility | | $2,217.07 | $2,217.07 | $2,217.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,217.07 / $2,217.07
| Professional | | $1,618.46 | $2,217.07 | $2,217.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $986.09 / $2,069.38 / $16,018.84
| Facility | | $986.09 | $2,069.38 | $16,018.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.29 / $2,018.42 / $3,487.95
| Professional | | $1,018.29 | $2,018.42 | $3,487.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.86 / $2,018.42 / $2,301.38
| Facility | | $1,176.86 | $2,018.42 | $2,301.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.29 / $1,642.29 / $2,300.87
| Professional | | $1,018.29 | $1,642.29 | $2,300.87 |