- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,591.00 / $2,641.81 / $2,641.81
| Facility | | $2,591.00 | $2,641.81 | $2,641.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.19 / $2,641.81 / $4,538.58
| Professional | | $2,540.19 | $2,641.81 | $4,538.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,633.17 / $5,488.08 / $5,488.08
| Professional | | $3,633.17 | $5,488.08 | $5,488.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,983.84 / $4,052.23 / $4,052.23
| Facility | | $2,983.84 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $2,958.13 / $4,052.23
| Professional | | $2,958.13 | $2,958.13 | $4,052.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,552.20 / $29,802.90 / $33,201.65
| Facility | | $9,552.20 | $29,802.90 | $33,201.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36,484.17 / $36,484.17 / $41,865.68
| Professional | | $36,484.17 | $36,484.17 | $41,865.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.10 / $3,042.16 / $4,196.66
| Professional | | $2,028.10 | $3,042.16 | $4,196.66 |