- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,269.32 / $2,269.32 / $5,826.64
| Facility | | $2,269.32 | $2,269.32 | $5,826.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.32 / $2,959.98 / $5,826.64
| Professional | | $2,269.32 | $2,959.98 | $5,826.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,004.41 / $7,004.41 / $7,004.41
| Facility | | $7,004.41 | $7,004.41 | $7,004.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.15 / $3,194.59 / $7,004.41
| Professional | | $3,155.15 | $3,194.59 | $7,004.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $5,156.49
| Facility | | $3,943.38 | $3,943.38 | $5,156.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $3,858.65 / $4,629.22
| Professional | | $2,878.67 | $3,858.65 | $4,629.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,895.07 / $5,603.53 / $9,105.73
| Professional | | $3,895.07 | $5,603.53 | $9,105.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.07 / $2,666.76 / $4,368.03
| Professional | | $2,052.07 | $2,666.76 | $4,368.03 |