- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,309.57 / $8,709.64
| Professional | | $5,623.41 | $6,309.57 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $8,912.51
| Professional | | $6,918.31 | $6,918.31 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $9,332.54
| Professional | | $6,606.93 | $6,606.93 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $18,197.01 / $25,118.86
| Professional | | $8,511.38 | $18,197.01 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $9,772.37
| Professional | | $4,265.80 | $6,309.57 | $9,772.37 |