- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,251.16 / $6,251.16 / $6,251.16
| Facility | | $6,251.16 | $6,251.16 | $6,251.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,251.16 / $7,987.08 / $10,994.28
| Professional | | $6,251.16 | $7,987.08 | $10,994.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,918.12 / $11,736.82 / $17,010.57
| Facility | | $9,918.12 | $11,736.82 | $17,010.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $8,567.87 / $14,895.05
| Professional | | $8,567.87 | $8,567.87 | $14,895.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,540.42 / $15,649.72 / $22,283.85
| Professional | | $15,540.42 | $15,649.72 | $22,283.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,611.89 / $17,010.57 / $17,010.57
| Professional | | $16,611.89 | $17,010.57 | $17,010.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,670.13 / $8,948.49 / $17,010.57
| Professional | | $7,670.13 | $8,948.49 | $17,010.57 |