- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,277.03 / $10,277.03 / $10,277.03
| Facility | | $10,277.03 | $10,277.03 | $10,277.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,358.65 / $10,414.04 / $12,817.34
| Professional | | $8,358.65 | $10,414.04 | $12,817.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,289.24 / $12,951.94 / $15,542.33
| Professional | | $10,289.24 | $12,951.94 | $15,542.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,587.24 / $10,102.62 / $10,102.62
| Professional | | $8,587.24 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $11,041.73 / $11,041.73
| Facility | | $64.00 | $11,041.73 | $11,041.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,502.05 / $5,356.07 / $7,296.19
| Professional | | $3,502.05 | $5,356.07 | $7,296.19 |