- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,741.40 / $6,741.40 / $6,884.48
| Facility | | $6,741.40 | $6,741.40 | $6,884.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,658.57 / $6,495.92 / $8,055.69
| Professional | | $4,658.57 | $6,495.92 | $8,055.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.77 / $2,202.13 / $2,439.30
| Facility | | $1,115.77 | $2,202.13 | $2,439.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,727.22 / $5,652.72 / $7,173.21
| Professional | | $4,727.22 | $5,652.72 | $7,173.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.68 / $3,704.40 / $6,026.06
| Professional | | $821.68 | $3,704.40 | $6,026.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.07 / $3,536.55 / $5,839.61
| Professional | | $2,455.07 | $3,536.55 | $5,839.61 |