- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.75 / $4,520.25 / $21,021.00
| Facility | | $1,947.75 | $4,520.25 | $21,021.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.75 / $2,756.25 / $3,123.75
| Professional | | $1,947.75 | $2,756.25 | $3,123.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,592.31 / $5,428.72 / $11,572.16
| Facility | | $3,592.31 | $5,428.72 | $11,572.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,858.75 / $4,814.25 / $6,695.85
| Professional | | $3,858.75 | $4,814.25 | $6,695.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $3,969.00
| Professional | | $1,543.50 | $2,205.00 | $3,969.00 |