- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,686.85 / $13,176.40 / $17,755.40
| Facility | | $4,686.85 | $13,176.40 | $17,755.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,672.47 / $7,131.15 / $12,058.13
| Professional | | $4,672.47 | $7,131.15 | $12,058.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $4,421.56 / $4,686.85
| Facility | | $4,421.56 | $4,421.56 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,983.82 / $3,983.82 / $4,686.85
| Professional | | $3,983.82 | $3,983.82 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.03 / $4,686.85 / $7,596.35
| Professional | | $4,265.03 | $4,686.85 | $7,596.35 |