- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,325.19 / $5,325.19 / $5,325.19
| Facility | | $5,325.19 | $5,325.19 | $5,325.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.41 / $3,766.57 / $5,325.19
| Professional | | $1,629.41 | $3,766.57 | $5,325.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,016.47 / $5,016.47 / $5,016.47
| Professional | | $5,016.47 | $5,016.47 | $5,016.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $7,331.25
| Professional | | $408.57 | $3,655.97 | $7,331.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,629.41 / $3,766.57 / $26,705.78
| Facility | | $1,629.41 | $3,766.57 | $26,705.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.45 / $1,907.48 / $3,002.19
| Professional | | $1,252.45 | $1,907.48 | $3,002.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.45 / $1,907.48 / $3,663.50
| Professional | | $1,252.45 | $1,907.48 | $3,663.50 |