- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $7,244.36
| Facility | | $4,677.35 | $4,677.35 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,570.88 / $7,244.36
| Professional | | $3,630.78 | $4,570.88 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,786.30
| Professional | | $4,073.80 | $4,073.80 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,760.83 / $10,232.93
| Facility | | $5,011.87 | $6,760.83 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,073.80 / $6,165.95
| Professional | | $2,511.89 | $4,073.80 | $6,165.95 |