- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $6,165.95
| Facility | | $3,311.31 | $3,311.31 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $4,168.69
| Professional | | $2,454.71 | $3,019.95 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.96 / $10.96 / $3,467.37
| Facility | | $10.96 | $10.96 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,467.37 / $3,467.37
| Professional | | $3,311.31 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,187.76 / $2,754.23
| Professional | | $2,041.74 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $8,317.64
| Facility | | $3,311.31 | $3,311.31 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,548.13 / $4,786.30
| Professional | | $2,884.03 | $3,548.13 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,187.76
| Professional | | $2,041.74 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,467.37 / $4,168.69
| Facility | | $3,162.28 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,467.37
| Professional | | $1,479.11 | $2,089.30 | $3,467.37 |