- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,248.07 / $9,120.11
| Professional | | $4,570.88 | $5,248.07 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Professional | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $11,481.54
| Facility | | $6,606.93 | $6,606.93 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $9,120.11
| Professional | | $4,897.79 | $4,897.79 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,025.60 / $8,317.64
| Facility | | $3,467.37 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,570.88 / $7,079.46
| Professional | | $4,168.69 | $4,570.88 | $7,079.46 |