- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,760.83 / $10,000.00
| Professional | | $5,128.61 | $6,760.83 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $8,317.64 / $13,182.57
| Professional | | $891.25 | $8,317.64 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $8,511.38 / $8,511.38
| Professional | | $7,762.47 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,174.90 / $7,762.47
| Facility | | $549.54 | $1,174.90 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $8,709.64
| Professional | | $3,630.78 | $5,128.61 | $8,709.64 |