- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,646.09 / $2,697.98 / $2,697.98
| Facility | | $2,646.09 | $2,697.98 | $2,697.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,646.09 / $2,894.73 / $4,729.89
| Professional | | $2,646.09 | $2,894.73 | $4,729.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,710.42 / $5,604.76 / $5,604.76
| Professional | | $3,710.42 | $5,604.76 | $5,604.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,328.84 / $4,366.38 / $4,366.38
| Facility | | $3,328.84 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $3,187.46 / $4,366.38
| Professional | | $3,187.46 | $3,187.46 | $4,366.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,702.07 / $33,390.44 / $39,440.91
| Facility | | $10,702.07 | $33,390.44 | $39,440.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45,658.26 / $46,754.06 / $49,888.58
| Professional | | $45,658.26 | $46,754.06 | $49,888.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.23 / $3,106.84 / $4,681.06
| Professional | | $2,071.23 | $3,106.84 | $4,681.06 |