- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,502.41 / $16,502.41 / $16,502.41
| Facility | | $16,502.41 | $16,502.41 | $16,502.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,502.41 / $18,792.59 / $18,792.59
| Professional | | $16,502.41 | $18,792.59 | $18,792.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,207.94 / $25,075.27 / $25,699.04
| Professional | | $21,207.94 | $25,075.27 | $25,699.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,010.38 / $26,270.48 / $33,033.18
| Professional | | $26,010.38 | $26,270.48 | $33,033.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,875.32 / $18,408.09 / $104,478.94
| Facility | | $9,875.32 | $18,408.09 | $104,478.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,036.32 / $14,998.82 / $18,343.73
| Professional | | $9,036.32 | $14,998.82 | $18,343.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,829.28 / $9,999.21 / $18,072.64
| Professional | | $7,829.28 | $9,999.21 | $18,072.64 |