- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,376.51 / $4,428.04 / $4,428.04
| Facility | | $4,376.51 | $4,428.04 | $4,428.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,428.04 / $4,428.04 / $4,428.04
| Professional | | $4,428.04 | $4,428.04 | $4,428.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,084.87 / $5,004.38 / $8,341.74
| Facility | | $4,084.87 | $5,004.38 | $8,341.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $3,817.28
| Professional | | $3,817.28 | $3,817.28 | $3,817.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.82 / $6,934.16 / $9,954.98
| Facility | | $5,011.82 | $6,934.16 | $9,954.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,626.42 / $3,817.28 / $4,249.43
| Professional | | $3,626.42 | $3,817.28 | $4,249.43 |