- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,351.03 / $9,351.03 / $9,351.03
| Facility | | $9,351.03 | $9,351.03 | $9,351.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,934.48 / $6,864.05 / $9,351.03
| Professional | | $3,934.48 | $6,864.05 | $9,351.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,793.86 / $5,793.86 / $5,793.86
| Professional | | $5,793.86 | $5,793.86 | $5,793.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.67 / $3,818.66 / $15,145.31
| Professional | | $738.67 | $3,818.66 | $15,145.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,934.48 / $6,864.05 / $9,013.86
| Facility | | $3,934.48 | $6,864.05 | $9,013.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.79 / $3,280.29 / $4,924.47
| Professional | | $1,969.79 | $3,280.29 | $4,924.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.79 / $3,280.29 / $5,186.39
| Professional | | $1,969.79 | $3,280.29 | $5,186.39 |