- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,258.12 / $13,012.46 / $18,481.47
| Facility | | $12,258.12 | $13,012.46 | $18,481.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,432.70 / $13,012.46 / $18,858.64
| Professional | | $9,432.70 | $13,012.46 | $18,858.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,741.22 / $33,724.91 / $47,404.96
| Facility | | $19,741.22 | $33,724.91 | $47,404.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,462.82 / $16,103.35 / $16,103.35
| Professional | | $13,462.82 | $16,103.35 | $16,103.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $11,736.82
| Facility | | $11,736.82 | $11,736.82 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $11,736.82 / $11,736.82
| Professional | | $8,567.87 | $11,736.82 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,657.59 / $11,315.18 / $17,751.61
| Professional | | $5,657.59 | $11,315.18 | $17,751.61 |