- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,754.40 / $5,754.40
| Facility | | $5,623.41 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,715.35 / $5,754.40
| Professional | | $2,951.21 | $3,715.35 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,709.64 / $9,549.93
| Professional | | $6,456.54 | $8,709.64 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $9,772.37
| Professional | | $7,762.47 | $7,762.47 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,456.54 / $33,113.11
| Facility | | $2,951.21 | $6,456.54 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,890.45 / $7,413.10
| Professional | | $2,818.38 | $3,890.45 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $10,232.93 / $10,232.93
| Facility | | $4,073.80 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,677.35 / $7,762.47
| Professional | | $2,454.71 | $4,677.35 | $7,762.47 |