- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,994.18 / $7,994.18 / $7,994.18
| Facility | | $7,994.18 | $7,994.18 | $7,994.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,501.93 / $8,100.76 / $9,970.23
| Professional | | $6,501.93 | $8,100.76 | $9,970.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,003.68 / $10,074.89 / $12,089.86
| Professional | | $8,003.68 | $10,074.89 | $12,089.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,343.04 / $4,343.04 / $14,831.25
| Professional | | $4,343.04 | $4,343.04 | $14,831.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $8,589.12 / $8,589.12
| Facility | | $64.00 | $8,589.12 | $8,589.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,836.69 / $4,166.37 / $5,576.80
| Professional | | $2,836.69 | $4,166.37 | $5,576.80 |