- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,476.52 / $8,476.52 / $8,476.52
| Facility | | $8,476.52 | $8,476.52 | $8,476.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,738.56
| Professional | | $2,608.16 | $2,608.16 | $2,738.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,543.89 / $2,543.89 / $3,010.31
| Facility | | $2,543.89 | $2,543.89 | $3,010.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Facility | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,903.43
| Professional | | $2,608.16 | $2,608.16 | $2,903.43 |