- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,918.31
| Professional | | $5,128.61 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,890.45 / $38,018.94
| Facility | | $2,951.21 | $3,890.45 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $10,471.29 / $10,471.29
| Professional | | $7,762.47 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $7,079.46
| Professional | | $5,623.41 | $5,623.41 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,128.61 / $5,128.61
| Professional | | $2,238.72 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Professional | | $5,623.41 | $5,623.41 | $5,623.41 |