- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,558.44 / $2,558.44 / $2,558.44
| Facility | | $2,558.44 | $2,558.44 | $2,558.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.36 / $2,558.44 / $2,708.49
| Professional | | $2,178.36 | $2,558.44 | $2,708.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,222.78 / $3,651.13 / $4,079.47
| Facility | | $3,222.78 | $3,651.13 | $4,079.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,257.26 / $3,129.41 / $4,130.82
| Professional | | $2,257.26 | $3,129.41 | $4,130.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.76 / $2,855.63 / $5,303.31
| Facility | | $346.76 | $2,855.63 | $5,303.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.76 / $2,651.66 / $4,895.35
| Professional | | $346.76 | $2,651.66 | $4,895.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $4,230.66
| Professional | | $2,271.73 | $2,672.64 | $4,230.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.85 / $2,047.28 / $3,120.86
| Professional | | $1,364.85 | $2,047.28 | $3,120.86 |