- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $4,168.69
| Facility | | $3,630.78 | $3,630.78 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $4,168.69
| Professional | | $2,089.30 | $2,630.27 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,495.41 / $6,025.60
| Professional | | $4,168.69 | $5,495.41 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $7,079.46
| Professional | | $5,754.40 | $5,754.40 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,168.69 / $22,908.68
| Facility | | $2,187.76 | $4,168.69 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $5,011.87
| Professional | | $1,995.26 | $2,511.89 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,244.36 / $7,244.36
| Facility | | $2,884.03 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,311.31 / $5,248.07
| Professional | | $1,737.80 | $3,311.31 | $5,248.07 |