- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,570.88 / $7,079.46
| Professional | | $3,162.28 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,606.93 / $8,128.31
| Facility | | $4,786.30 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,606.93
| Professional | | $4,786.30 | $4,786.30 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $8,511.38 / $11,748.98
| Professional | | $5,370.32 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Professional | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,025.60 / $9,332.54
| Facility | | $3,801.89 | $6,025.60 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,168.69 / $6,760.83
| Professional | | $3,630.78 | $4,168.69 | $6,760.83 |