- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.35 / $839.35 / $11,017.30
| Professional | | $839.35 | $839.35 | $11,017.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,142.38 / $14,142.38 / $14,142.38
| Facility | | $14,142.38 | $14,142.38 | $14,142.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.00 / $1,678.00 / $14,142.38
| Professional | | $1,678.00 | $1,678.00 | $14,142.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,594.58 / $14,594.58 / $14,594.58
| Facility | | $14,594.58 | $14,594.58 | $14,594.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,814.46 / $11,203.88 / $22,919.17
| Professional | | $8,814.46 | $11,203.88 | $22,919.17 |