- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,011.87 / $8,709.64
| Professional | | $3,981.07 | $5,011.87 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $10,471.29
| Facility | | $6,606.93 | $6,606.93 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,606.93
| Professional | | $4,897.79 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,964.78 / $15,135.61
| Professional | | $6,760.83 | $10,964.78 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Professional | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $10,232.93 / $12,589.25
| Facility | | $6,025.60 | $10,232.93 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,370.32 / $8,317.64
| Professional | | $4,570.88 | $5,370.32 | $8,317.64 |