- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,582.20 / $7,582.20 / $16,112.20
| Facility | | $7,582.20 | $7,582.20 | $16,112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $2,666.54 / $2,666.54
| Professional | | $2,666.54 | $2,666.54 | $2,666.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,032.88 / $3,032.88 / $4,928.43
| Professional | | $3,032.88 | $3,032.88 | $4,928.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,582.20 / $7,582.20 / $7,658.02
| Professional | | $7,582.20 | $7,582.20 | $7,658.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,582.20 / $7,582.20 / $12,283.20
| Facility | | $7,582.20 | $7,582.20 | $12,283.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $2,666.54 / $7,582.20
| Professional | | $2,666.54 | $2,666.54 | $7,582.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,549.32 / $4,549.32 / $11,373.30
| Professional | | $4,549.32 | $4,549.32 | $11,373.30 |