- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,429.22 / $4,429.22 / $4,429.22
| Facility | | $4,429.22 | $4,429.22 | $4,429.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,020.77 / $4,821.74 / $4,821.74
| Professional | | $4,020.77 | $4,821.74 | $4,821.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,692.19 / $6,730.17 / $6,897.59
| Professional | | $5,692.19 | $6,730.17 | $6,897.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,673.50 / $6,740.24 / $8,475.35
| Professional | | $6,673.50 | $6,740.24 | $8,475.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,189.94 / $4,507.22 / $24,371.76
| Facility | | $2,189.94 | $4,507.22 | $24,371.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,172.40 / $3,416.83 / $4,850.68
| Professional | | $2,172.40 | $3,416.83 | $4,850.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.59 / $3,416.83 / $4,850.68
| Professional | | $1,518.59 | $3,416.83 | $4,850.68 |