- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,922.06 / $3,506.47 / $3,506.47
| Facility | | $2,922.06 | $3,506.47 | $3,506.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.42 / $3,506.48 / $4,090.89
| Facility | | $2,571.42 | $3,506.48 | $4,090.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.18 / $2,805.18 / $3,155.83
| Professional | | $2,805.18 | $2,805.18 | $3,155.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,899.34 / $2,805.18 / $7,012.35
| Facility | | $1,899.34 | $2,805.18 | $7,012.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,267.47 / $11,267.47 / $11,267.47
| Professional | | $11,267.47 | $11,267.47 | $11,267.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $1,168.83 / $3,389.59
| Professional | | $981.81 | $1,168.83 | $3,389.59 |