- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,861.72 / $5,210.58 / $7,581.75
| Facility | | $2,861.72 | $5,210.58 | $7,581.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,087.97 / $5,210.58 / $5,210.58
| Professional | | $5,087.97 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,823.59 / $5,823.59 / $5,823.59
| Facility | | $5,823.59 | $5,823.59 | $5,823.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,823.59 / $5,823.59 / $5,823.59
| Professional | | $5,823.59 | $5,823.59 | $5,823.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,417.26 / $5,210.58 / $6,022.26
| Facility | | $3,417.26 | $5,210.58 | $6,022.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $5,261.66
| Professional | | $5,108.41 | $5,108.41 | $5,261.66 |