- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,491.85 / $5,491.85 / $5,491.85
| Facility | | $5,491.85 | $5,491.85 | $5,491.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,134.05 / $5,491.85 / $7,822.03
| Professional | | $3,134.05 | $5,491.85 | $7,822.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,983.70 / $12,341.29 / $22,406.75
| Facility | | $10,983.70 | $12,341.29 | $22,406.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,543.68 / $6,543.68 / $7,067.17
| Professional | | $6,543.68 | $6,543.68 | $7,067.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $7,503.37
| Facility | | $7,503.37 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $5,477.46 / $10,817.15
| Professional | | $5,477.46 | $5,477.46 | $10,817.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.15 / $5,491.85 / $13,729.63
| Facility | | $3,034.15 | $5,491.85 | $13,729.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,034.15 / $3,034.15 / $3,034.15
| Professional | | $3,034.15 | $3,034.15 | $3,034.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,018.10 / $13,729.63 / $21,747.73
| Professional | | $8,018.10 | $13,729.63 | $21,747.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,345.39 / $4,699.85 / $7,242.34
| Professional | | $4,345.39 | $4,699.85 | $7,242.34 |