- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $13,182.57
| Facility | | $2,691.53 | $2,691.53 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,128.61 / $7,079.46
| Professional | | $2,691.53 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $10,232.93
| Professional | | $6,760.83 | $6,760.83 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $9,772.37 / $14,125.38
| Facility | | $4,897.79 | $9,772.37 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $7,585.78
| Facility | | $6,760.83 | $6,760.83 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,570.88 / $7,585.78
| Professional | | $3,162.28 | $4,570.88 | $7,585.78 |