- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,544.15 / $2,544.15 / $2,679.84
| Facility | | $2,544.15 | $2,544.15 | $2,679.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.30 / $2,544.15 / $3,173.03
| Professional | | $2,037.30 | $2,544.15 | $3,173.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.09 / $3,206.39 / $3,847.66
| Professional | | $2,547.09 | $3,206.39 | $3,847.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.98 / $2,837.98 / $4,136.25
| Professional | | $2,837.98 | $2,837.98 | $4,136.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,729.48 / $18,269.96 / $18,936.02
| Facility | | $3,729.48 | $18,269.96 | $18,936.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.08 / $1,468.34 / $2,282.42
| Professional | | $1,027.08 | $1,468.34 | $2,282.42 |