- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.57 / $2,677.57 / $2,677.57
| Facility | | $2,677.57 | $2,677.57 | $2,677.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.49 / $2,677.57 / $2,879.85
| Professional | | $2,662.49 | $2,677.57 | $2,879.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,586.34 / $7,371.62 / $9,555.81
| Facility | | $3,586.34 | $7,371.62 | $9,555.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,549.30 / $3,862.22 / $6,620.94
| Professional | | $3,549.30 | $3,862.22 | $6,620.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $6,587.35
| Facility | | $3,728.42 | $3,728.42 | $6,587.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $27,609.59
| Professional | | $2,721.75 | $3,728.42 | $27,609.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,724.16 / $3,856.19 / $5,329.30
| Professional | | $2,724.16 | $3,856.19 | $5,329.30 |