- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,800.51 / $4,800.51 / $4,800.51
| Facility | | $4,800.51 | $4,800.51 | $4,800.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,175.49 / $4,800.51 / $5,081.70
| Professional | | $4,175.49 | $4,800.51 | $5,081.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,458.07 / $5,723.24 / $7,165.30
| Professional | | $5,458.07 | $5,723.24 | $7,165.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.79 / $1,010.62 / $10,248.93
| Facility | | $660.79 | $1,010.62 | $10,248.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.31 / $932.88 / $12,298.72
| Professional | | $505.31 | $932.88 | $12,298.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $4,775.22 / $7,531.79
| Professional | | $615.41 | $4,775.22 | $7,531.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,560.48 / $3,840.72 / $5,894.10
| Professional | | $2,560.48 | $3,840.72 | $5,894.10 |