- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,606.93 / $8,128.31
| Professional | | $5,754.40 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,317.64 / $10,000.00
| Professional | | $6,606.93 | $8,317.64 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $6,606.93
| Facility | | $5,128.61 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $6,606.93
| Professional | | $5,495.41 | $5,495.41 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $7,079.46 / $7,079.46
| Facility | | $64.57 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $707.95 / $4,677.35
| Facility | | $407.38 | $707.95 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,467.37 / $4,677.35
| Professional | | $2,089.30 | $3,467.37 | $4,677.35 |