- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.76 / $7,580.00 / $7,580.00
| Professional | | $3,715.76 | $7,580.00 | $7,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,839.46 / $4,839.46 / $4,839.46
| Facility | | $4,839.46 | $4,839.46 | $4,839.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,839.46 / $4,839.46 / $4,839.46
| Professional | | $4,839.46 | $4,839.46 | $4,839.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.35 / $1,901.21 / $4,839.46
| Facility | | $168.35 | $1,901.21 | $4,839.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.39 / $2,851.81 / $7,659.89
| Professional | | $185.39 | $2,851.81 | $7,659.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,280.03 / $6,211.81 / $8,512.76
| Professional | | $5,280.03 | $6,211.81 | $8,512.76 |