- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $5,075.03
| Professional | | $5,075.03 | $5,075.03 | $5,075.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,289.62 / $6,745.34 / $7,813.91
| Facility | | $5,289.62 | $6,745.34 | $7,813.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,451.32 / $5,451.32 / $5,451.32
| Facility | | $5,451.32 | $5,451.32 | $5,451.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,911.94 / $5,911.94 / $5,911.94
| Professional | | $5,911.94 | $5,911.94 | $5,911.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,110.93 / $3,110.93 / $3,110.93
| Professional | | $3,110.93 | $3,110.93 | $3,110.93 |