- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,116.00 / $5,702.28 / $6,325.48
| Facility | | $3,116.00 | $5,702.28 | $6,325.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,461.64 / $5,702.28 / $6,325.48
| Professional | | $2,461.64 | $5,702.28 | $6,325.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,702.85 / $3,702.85 / $3,702.85
| Facility | | $3,702.85 | $3,702.85 | $3,702.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,702.85 / $3,702.85 / $3,702.85
| Professional | | $3,702.85 | $3,702.85 | $3,702.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.40 / $2,126.67 / $2,612.77
| Facility | | $2,025.40 | $2,126.67 | $2,612.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.64 / $1,419.10 / $4,282.05
| Professional | | $1,333.64 | $1,419.10 | $4,282.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.72 / $1,869.60 / $4,688.60
| Professional | | $1,308.72 | $1,869.60 | $4,688.60 |