- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,677.35 / $4,677.35
| Facility | | $2,691.53 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $4,677.35
| Professional | | $2,344.23 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,165.95 / $11,748.98
| Facility | | $5,495.41 | $6,165.95 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $4,265.80
| Professional | | $3,235.94 | $3,235.94 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $4,168.69
| Professional | | $2,951.21 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,495.41 / $15,848.93
| Professional | | $3,235.94 | $5,495.41 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,495.41 / $5,495.41
| Professional | | $5,370.32 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,548.13 / $4,073.80
| Facility | | $2,398.83 | $3,548.13 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $4,073.80
| Professional | | $2,398.83 | $2,691.53 | $4,073.80 |