- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $6,606.93 / $7,943.28
| Facility | | $371.54 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,585.78
| Professional | | $7,413.10 | $7,413.10 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $19,498.45 / $28,840.32
| Facility | | $7,585.78 | $19,498.45 | $28,840.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Facility | | $6,165.95 | $6,165.95 | $6,165.95 |