- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $5,495.41
| Facility | | $4,466.84 | $4,466.84 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,630.78 / $5,495.41
| Professional | | $3,235.94 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,120.11 / $11,481.54
| Professional | | $6,760.83 | $9,120.11 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,370.32 / $8,709.64
| Facility | | $4,466.84 | $5,370.32 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $23,988.33
| Professional | | $2,454.71 | $2,884.03 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $11,220.18 / $13,182.57
| Professional | | $6,760.83 | $11,220.18 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $5,495.41
| Professional | | $1,995.26 | $2,884.03 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |