- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $7,943.28
| Facility | | $4,265.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,220.18 / $11,220.18
| Professional | | $5,370.32 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $10,471.29 / $10,471.29
| Professional | | $151.36 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,762.47 / $13,489.63
| Facility | | $4,897.79 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $13,182.57
| Facility | | $4,365.16 | $7,079.46 | $13,182.57 |