- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,055.10 / $4,055.10 / $6,336.10
| Facility | | $4,055.10 | $4,055.10 | $6,336.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,806.54 / $5,895.71 / $6,336.10
| Professional | | $3,806.54 | $5,895.71 | $6,336.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,716.85 / $6,716.85 / $7,388.54
| Facility | | $6,716.85 | $6,716.85 | $7,388.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,765.46 / $5,765.46 / $5,765.46
| Professional | | $5,765.46 | $5,765.46 | $5,765.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $3,454.31 / $4,063.89
| Professional | | $3,454.31 | $3,454.31 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.08 / $3,609.97 / $5,715.78
| Professional | | $2,163.08 | $3,609.97 | $5,715.78 |