- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,550.21 / $3,619.82 / $3,619.82
| Facility | | $3,550.21 | $3,619.82 | $3,619.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,550.21 / $3,662.54 / $6,218.78
| Professional | | $3,550.21 | $3,662.54 | $6,218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,978.18 / $7,519.79 / $7,519.79
| Professional | | $4,978.18 | $7,519.79 | $7,519.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $4,751.45
| Facility | | $4,751.45 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,038.73 / $4,751.45
| Professional | | $4,038.73 | $4,038.73 | $4,751.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,055.18 / $39,447.21 / $41,007.75
| Facility | | $13,055.18 | $39,447.21 | $41,007.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42,201.91 / $42,201.91 / $63,121.35
| Professional | | $42,201.91 | $42,201.91 | $63,121.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,778.92 / $4,168.38 / $5,715.75
| Professional | | $2,778.92 | $4,168.38 | $5,715.75 |