- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,079.46 / $12,302.69
| Professional | | $5,623.41 | $7,079.46 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $9,332.54 / $14,791.08
| Facility | | $8,511.38 | $9,332.54 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $9,332.54
| Professional | | $6,918.31 | $6,918.31 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $15,488.17 / $21,379.62
| Professional | | $9,549.93 | $15,488.17 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Professional | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $10,715.19 / $16,595.87
| Facility | | $6,025.60 | $10,715.19 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,585.78 / $11,748.98
| Professional | | $6,456.54 | $7,585.78 | $11,748.98 |