- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,863.36 / $3,863.36 / $3,863.36
| Facility | | $3,863.36 | $3,863.36 | $3,863.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,863.36 / $6,020.75 / $11,412.47
| Professional | | $3,863.36 | $6,020.75 | $11,412.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.31 / $4,232.09 / $4,978.93
| Professional | | $725.31 | $4,232.09 | $4,978.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,863.36 / $6,380.20 / $10,744.80
| Facility | | $3,863.36 | $6,380.20 | $10,744.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.94 / $974.94 / $1,026.25
| Professional | | $974.94 | $974.94 | $1,026.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.88 / $504.91 / $3,698.11
| Professional | | $307.88 | $504.91 | $3,698.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.24 / $3,455.40 / $4,593.63
| Professional | | $2,901.24 | $3,455.40 | $4,593.63 |