- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,697.25 / $2,750.14 / $2,750.14
| Facility | | $2,697.25 | $2,750.14 | $2,750.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.57 / $2,750.14 / $4,724.68
| Professional | | $2,659.57 | $2,750.14 | $4,724.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,782.14 / $5,713.13 / $5,713.13
| Professional | | $3,782.14 | $5,713.13 | $5,713.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,242.49 / $3,790.37 / $3,790.37
| Facility | | $3,242.49 | $3,790.37 | $3,790.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $2,766.97 / $3,790.37
| Professional | | $2,766.97 | $2,766.97 | $3,790.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,388.70 / $32,412.74 / $38,417.86
| Facility | | $10,388.70 | $32,412.74 | $38,417.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51,633.18 / $52,872.39 / $52,872.39
| Professional | | $51,633.18 | $52,872.39 | $52,872.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.27 / $3,166.90 / $4,559.63
| Professional | | $2,111.27 | $3,166.90 | $4,559.63 |