- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,614.17 / $2,665.44 / $2,665.44
| Facility | | $2,614.17 | $2,665.44 | $2,665.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,614.17 / $2,665.44 / $4,863.00
| Professional | | $2,614.17 | $2,665.44 | $4,863.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,665.66 / $5,537.17 / $5,537.17
| Professional | | $3,665.66 | $5,537.17 | $5,537.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,266.69 / $4,728.96 / $4,728.96
| Facility | | $3,266.69 | $4,728.96 | $4,728.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $3,452.14 / $4,728.96
| Professional | | $3,452.14 | $3,452.14 | $4,728.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,026.46 / $34,402.54 / $38,704.47
| Facility | | $11,026.46 | $34,402.54 | $38,704.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52,107.80 / $53,358.39 / $53,358.39
| Professional | | $52,107.80 | $53,358.39 | $53,358.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,046.25 / $3,069.37 / $4,593.64
| Professional | | $2,046.25 | $3,069.37 | $4,593.64 |