- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,656.18 / $7,656.18 / $7,656.18
| Facility | | $7,656.18 | $7,656.18 | $7,656.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,656.18 / $7,656.18 / $8,234.60
| Professional | | $7,656.18 | $7,656.18 | $8,234.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,554.77 / $21,078.25 / $27,323.66
| Facility | | $10,554.77 | $21,078.25 | $27,323.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,148.79 / $11,366.68 / $19,485.73
| Professional | | $10,148.79 | $11,366.68 | $19,485.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,907.40 / $9,907.40 / $19,029.04
| Facility | | $9,907.40 | $9,907.40 | $19,029.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,232.40 / $9,907.40 / $77,323.21
| Professional | | $7,232.40 | $9,907.40 | $77,323.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,789.42 / $10,075.86 / $13,040.65
| Professional | | $7,789.42 | $10,075.86 | $13,040.65 |