- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,601.45 / $7,601.45 / $7,601.45
| Facility | | $7,601.45 | $7,601.45 | $7,601.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,034.15 / $5,292.15 / $8,467.44
| Professional | | $3,034.15 | $5,292.15 | $8,467.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,759.33 / $8,759.33 / $8,759.33
| Professional | | $8,759.33 | $8,759.33 | $8,759.33 |
- 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 / $7,503.37 / $15,582.66
| Professional | | $5,477.46 | $7,503.37 | $15,582.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.15 / $8,147.20 / $48,813.24
| Facility | | $3,034.15 | $8,147.20 | $48,813.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.24 / $5,788.29 / $12,915.12
| Professional | | $3,133.24 | $5,788.29 | $12,915.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,362.25 / $5,043.37 / $7,242.34
| Professional | | $3,362.25 | $5,043.37 | $7,242.34 |