- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,748.58 / $2,748.58 / $2,748.58
| Facility | | $2,748.58 | $2,748.58 | $2,748.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,724.35 / $2,748.58 / $2,956.24
| Professional | | $2,724.35 | $2,748.58 | $2,956.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,753.12 / $7,567.11 / $9,809.21
| Facility | | $3,753.12 | $7,567.11 | $9,809.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,643.43 / $4,041.82 / $6,928.84
| Professional | | $3,643.43 | $4,041.82 | $6,928.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $6,766.44
| Facility | | $4,536.46 | $4,536.46 | $6,766.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $27,549.34
| Professional | | $3,855.99 | $4,536.46 | $27,549.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.88 / $6,907.88 / $6,907.88
| Facility | | $6,907.88 | $6,907.88 | $6,907.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.41 / $3,856.41 / $4,872.58
| Professional | | $2,796.41 | $3,856.41 | $4,872.58 |