- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.79 / $3,162.79 / $3,162.79
| Facility | | $3,162.79 | $3,162.79 | $3,162.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.79 / $3,407.01 / $4,544.72
| Professional | | $3,162.79 | $3,407.01 | $4,544.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,531.97 / $4,938.58 / $8,606.54
| Facility | | $4,531.97 | $4,938.58 | $8,606.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $3,605.16 / $7,536.18
| Professional | | $3,605.16 | $3,605.16 | $7,536.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,862.71 / $7,918.02 / $11,274.57
| Professional | | $7,862.71 | $7,918.02 | $11,274.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,404.82 / $8,606.54 / $8,606.54
| Professional | | $8,404.82 | $8,606.54 | $8,606.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,802.00 / $4,600.54 / $7,901.23
| Professional | | $3,802.00 | $4,600.54 | $7,901.23 |