- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.88 / $2,591.62 / $2,796.13
| Professional | | $2,059.88 | $2,591.62 | $2,796.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,665.58 / $9,002.76 / $10,658.21
| Facility | | $6,665.58 | $9,002.76 | $10,658.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,617.40 / $3,079.29 / $4,263.35
| Professional | | $2,617.40 | $3,079.29 | $4,263.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $2,886.72
| Facility | | $2,886.72 | $2,886.72 | $2,886.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,886.72 / $2,886.72
| Professional | | $2,107.31 | $2,886.72 | $2,886.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,753.36 / $5,753.36 / $5,753.36
| Facility | | $5,753.36 | $5,753.36 | $5,753.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.77 / $2,731.35 / $3,920.00
| Professional | | $2,125.77 | $2,731.35 | $3,920.00 |