- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,156.35 / $4,156.35 / $4,156.35
| Facility | | $4,156.35 | $4,156.35 | $4,156.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,119.68 / $4,156.35 / $4,470.35
| Professional | | $4,119.68 | $4,156.35 | $4,470.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,675.44 / $11,442.86 / $14,833.33
| Facility | | $5,675.44 | $11,442.86 | $14,833.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,509.52 / $6,112.01 / $10,477.73
| Professional | | $5,509.52 | $6,112.01 | $10,477.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,042.00 / $6,042.00 / $10,232.16
| Facility | | $6,042.00 | $6,042.00 | $10,232.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,410.66 / $6,042.00 / $41,719.61
| Professional | | $4,410.66 | $6,042.00 | $41,719.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,228.67 / $5,406.58 / $7,047.79
| Professional | | $4,228.67 | $5,406.58 | $7,047.79 |