- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,968.61 / $2,968.61 / $2,968.61
| Facility | | $2,968.61 | $2,968.61 | $2,968.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,466.01 / $2,466.01 / $2,968.61
| Professional | | $2,466.01 | $2,466.01 | $2,968.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,706.41 / $5,507.58 / $5,602.78
| Professional | | $4,706.41 | $5,507.58 | $5,602.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,777.50 / $4,825.28 / $6,067.43
| Professional | | $4,777.50 | $4,825.28 | $6,067.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,327.02 / $2,968.61 / $21,753.30
| Facility | | $2,327.02 | $2,968.61 | $21,753.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.70 / $2,427.25 / $3,640.88
| Professional | | $1,641.70 | $2,427.25 | $3,640.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.08 / $2,427.25 / $3,975.38
| Professional | | $1,357.08 | $2,427.25 | $3,975.38 |