- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,295.27 / $2,295.27 / $2,295.27
| Facility | | $2,295.27 | $2,295.27 | $2,295.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.27 / $2,328.01 / $20,732.00
| Professional | | $2,295.27 | $2,328.01 | $20,732.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.58 / $4,938.58 / $4,938.58
| Facility | | $4,938.58 | $4,938.58 | $4,938.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $4,938.58 / $5,086.74
| Professional | | $3,605.16 | $4,938.58 | $5,086.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.45 / $5,592.67 / $7,270.47
| Professional | | $3,467.45 | $5,592.67 | $7,270.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,708.18 / $7,481.38 / $7,481.38
| Facility | | $6,708.18 | $7,481.38 | $7,481.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,260.14 / $5,362.65 / $8,043.98
| Professional | | $4,260.14 | $5,362.65 | $8,043.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,210.17 / $3,555.35 / $5,100.60
| Professional | | $3,210.17 | $3,555.35 | $5,100.60 |