- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,047.40 / $8,047.40 / $8,047.40
| Facility | | $8,047.40 | $8,047.40 | $8,047.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,047.40 / $9,779.29 / $14,237.72
| Professional | | $8,047.40 | $9,779.29 | $14,237.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $21,898.50
| Facility | | $14,513.81 | $14,513.81 | $21,898.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,595.08 / $10,595.08 / $19,175.09
| Professional | | $10,595.08 | $10,595.08 | $19,175.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,005.89 / $20,146.62 / $28,687.04
| Professional | | $20,005.89 | $20,146.62 | $28,687.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,641.00 / $3,111.00
| Facility | | $1,080.00 | $1,641.00 | $3,111.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,385.25 / $21,898.50 / $21,898.50
| Professional | | $21,385.25 | $21,898.50 | $21,898.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,874.11 / $11,264.90 / $21,898.50
| Professional | | $9,874.11 | $11,264.90 | $21,898.50 |