- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $9,772.37
| Facility | | $3,801.89 | $3,801.89 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,168.69 / $5,128.61
| Professional | | $3,801.89 | $4,168.69 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $10,964.78 / $12,302.69
| Professional | | $7,943.28 | $10,964.78 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $7,943.28
| Professional | | $6,309.57 | $6,309.57 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,168.69 / $9,772.37
| Facility | | $3,311.31 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,456.54 / $10,964.78
| Professional | | $2,290.87 | $6,456.54 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,623.41 / $9,332.54
| Professional | | $2,290.87 | $5,623.41 | $9,332.54 |