- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.38 / $2,390.35 / $2,390.35
| Facility | | $2,344.38 | $2,390.35 | $2,390.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.38 / $2,390.35 / $4,106.58
| Professional | | $2,344.38 | $2,390.35 | $4,106.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,287.34 / $4,965.71 / $4,965.71
| Professional | | $3,287.34 | $4,965.71 | $4,965.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $2,721.75 / $3,728.42
| Professional | | $2,721.75 | $2,721.75 | $3,728.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,621.01 / $26,807.65 / $29,247.41
| Facility | | $8,621.01 | $26,807.65 | $29,247.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,647.77 / $30,647.77 / $38,967.68
| Professional | | $30,647.77 | $30,647.77 | $38,967.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.06 / $2,752.59 / $3,860.90
| Professional | | $1,835.06 | $2,752.59 | $3,860.90 |