- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,573.96 / $2,573.96 / $2,573.96
| Facility | | $2,573.96 | $2,573.96 | $2,573.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.87 / $2,393.58 / $2,573.96
| Professional | | $2,126.87 | $2,393.58 | $2,573.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,104.33 / $5,295.91 / $6,059.05
| Facility | | $4,104.33 | $5,295.91 | $6,059.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,694.05 / $2,694.05 / $2,862.43
| Professional | | $2,694.05 | $2,694.05 | $2,862.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $2,802.84
| Facility | | $2,802.84 | $2,802.84 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,382.41 / $2,802.84
| Professional | | $2,382.41 | $2,382.41 | $2,802.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,442.34 / $3,442.34 / $3,442.34
| Facility | | $3,442.34 | $3,442.34 | $3,442.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,442.34 / $3,575.15 / $5,060.21
| Professional | | $3,442.34 | $3,575.15 | $5,060.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.29 / $2,642.07 / $3,448.38
| Professional | | $2,016.29 | $2,642.07 | $3,448.38 |