- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $5,248.07
| Professional | | $2,187.76 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,754.40
| Facility | | $4,073.80 | $4,073.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $4,073.80
| Professional | | $2,951.21 | $2,951.21 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $8,317.64
| Professional | | $3,715.35 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Professional | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,623.41 / $7,585.78
| Facility | | $3,715.35 | $5,623.41 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,951.21 / $4,570.88
| Professional | | $2,511.89 | $2,951.21 | $4,570.88 |