- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,322.56 / $6,322.56 / $6,322.56
| Facility | | $6,322.56 | $6,322.56 | $6,322.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,322.56 / $6,322.56 / $7,454.96
| Professional | | $6,322.56 | $6,322.56 | $7,454.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,713.79 / $9,585.19 / $9,682.01
| Professional | | $8,713.79 | $9,585.19 | $9,682.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $10,905.82 / $10,905.82
| Facility | | $7,261.93 | $10,905.82 | $10,905.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,608.70 / $12,525.00 / $16,816.98
| Professional | | $10,608.70 | $12,525.00 | $16,816.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,412.74 / $10,852.16 / $48,028.87
| Facility | | $5,412.74 | $10,852.16 | $48,028.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,774.66 / $6,132.80 / $8,243.62
| Professional | | $3,774.66 | $6,132.80 | $8,243.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,873.92 / $10,905.82 / $14,048.41
| Facility | | $10,873.92 | $10,905.82 | $14,048.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,931.90 / $13,070.71 / $22,467.75
| Professional | | $8,931.90 | $13,070.71 | $22,467.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,774.66 / $4,946.17 / $7,109.25
| Professional | | $3,774.66 | $4,946.17 | $7,109.25 |