- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,808.43 / $9,808.43 / $9,808.43
| Facility | | $9,808.43 | $9,808.43 | $9,808.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,313.68 / $7,199.81 / $9,808.43
| Professional | | $4,313.68 | $7,199.81 | $9,808.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $7,608.68 / $15,801.56
| Professional | | $816.92 | $7,608.68 | $15,801.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.39 / $6,452.33 / $9,182.36
| Facility | | $923.39 | $6,452.33 | $9,182.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.21 / $3,618.00 / $5,623.80
| Professional | | $2,238.21 | $3,618.00 | $5,623.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.21 / $3,618.00 / $5,595.53
| Professional | | $2,238.21 | $3,618.00 | $5,595.53 |