- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,395.48 / $5,395.48 / $5,395.48
| Facility | | $5,395.48 | $5,395.48 | $5,395.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,395.48 / $5,395.48 / $5,803.10
| Professional | | $5,395.48 | $5,395.48 | $5,803.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,152.08 / $14,759.58 / $19,255.59
| Facility | | $7,152.08 | $14,759.58 | $19,255.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,152.08 / $7,702.24 / $12,740.17
| Professional | | $7,152.08 | $7,702.24 | $12,740.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,302.44 / $8,302.44 / $13,876.56
| Facility | | $8,302.44 | $8,302.44 | $13,876.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $8,302.44 / $58,160.87
| Professional | | $6,060.78 | $8,302.44 | $58,160.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,374.82 / $7,398.89 / $9,557.61
| Professional | | $5,374.82 | $7,398.89 | $9,557.61 |